That prompted introspection, he says, because back then, "surgeons weren't particularly worried about UTIs; surgeons are concerned about excess bleeding and leakage. But UTIs cause a lot of harm."
They looked in the literature to see how to prevent UTIs and decided to focus on Foley catheter necessity and duration, for starters, followed by use of impregnated catheters. "We made all these different changes, and then looked at our UTI rates again. They went from 7% to 1.8% the next year."
They didn't stop with that success; they kept looking.
As time passed, they noticed that without ongoing focus on the problem "UTIs popped back up to 3% in FY 2006, which at the time was 0.4% greater than the national average. We reinstituted some of our efforts and, sure enough, brought the number back down to 1.4% by FY 2007. We wouldn't have known there was a problem if we didn't measure it, implement changes, and even after seeing improvement, track the metric over time."
Throughout participating NSQIP hospitals nationally, quality improved, with vascular surgery UTI rates dropping from 4.9% to 2.0% over just four years, demonstrating that collective efforts raised overall quality level for all surgery "quite dramatically," says Hutter. Without comparative national NSQIP data, a hospital wouldn't know that even though it had improved, it still could be worse than other hospitals.
Hutter says MGH also took on overall complication rates for colectomy procedures as part of a surgical collaborative of the Partners hospitals in the Boston area. "At MGH we decreased our rates from 37% during a 12-month period from July 2006 to June 2007, to 19% over a period covering calendar year 2008. We cut our complication rates in half in one year." Over that time period, the collaborative decreased colectomy complication rates from 29.1% to 22.4% from 2007 to 2008. Pancreatic resection complications decreased by one-third at MGH.
The program does cost money. NSQIP charged all hospitals $35,000 for a one-year participation, although annual fees have since been reduced between $10,000 and $25,000 depending on hospital size and extent of the program, Ko says. Each hospital also must provide a surgical-clinical reviewer who both collects data and initiates quality improvement projects, and is trained and credentialed by the NSQIP program. But still, those amounts are relatively small enough to make an attractive business case for the program.
Hutter points out that each complication costs on average $11,000, as determined by Justin Demick and colleagues at the University of Michigan. "So if you can reduce your number of complications, at $11,000 per complication, you more than offset the cost of the program."