Patient Safety Indicators Are Insufficient To Grade Open Aortic Surgery Programs: a Comparison of Contemporary National Outcomes Measures
Rebecca Sorber, Katherine A Giuliano, Caitlin W Hicks, James H Black, III
The Johns Hopkins Hospital, Baltimore, MD
INTRODUCTION: National rankings of hospitals rely on outcomes-based evaluation to assess the performance of surgical programs, particularly those performing high-risk elective surgical procedures such as open aortic repair. There exist various systems for tracking outcomes, but increasingly the ICD-10 based Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are utilized as a publicly reported and rankable measure of hospital quality performance. Within vascular surgery, the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) and the Society for Vascular Surgery Vascular Quality Improvement (SVS-VQI) databases are also widely employed to compare clinical outcomes, but the definitions of postoperative complications vary considerably amongst all of these classification systems. We sought to investigate the accuracy of the existing vehicles to assess vascular surgery outcomes in an established complex aortic program. METHODS: This is a case-control study of patients who underwent open abdominal aortic aneurysm (AAA) repair at the Johns Hopkins Medical Institutions from 2004-2018. Patient characteristics and outcomes were collected as part of a prospectively maintained retrospective database and confirmed via retrospective chart review. For each case, hemorrhagic, cardiac, respiratory, renal, wound and thromboembolic complications were identified using the unique definitions utilized for open AAA repair by the ACS-NSQIP database, the SVS-VQI database, and the AHRQ-PSI initiative. All data were analyzed using Stata Version 15.1. RESULTS: Of the 155 patients included in the study, 79 (51.0%) were identified as having a complication as defined by VQI, 46 (29.7%) according to the NSQIP system and 15 (9.7%) according to PSI (p<0.001). Patients most likely to incur a complication in the PSI system were those with a pararenal or more extensive aneurysm, baseline congestive heart failure, requiring a supramesenteric clamp (all p<0.01), or an aneurysm exceeding 6.5cm in diameter (p=0.02). The NSQIP and VQI systems both identified more postoperative hemorrhagic, respiratory, renal and wound complications than PSI (p<0.05). The VQI system identified the most renal complications (52, p<0.001); factors unique to incurring a complication in VQI include use of a suprarenal clamp or performance of an aortorenal bypass procedure as part of the repair (p<0.01). CONCLUSIONS: Patient safety indicators identified fewer important complications than either of the clinically-focused databases, with the VQI capturing the most post-operative events, mostly due to its stringent definition of renal injury. We conclude PSI should not form the basis of grading hospital performance when comparing clinically relevant complications among open aortic surgery programs.
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