The Right Stuff: Veterans Affairs National Surgical Quality Improvement Project

Abstract

Robert S. Lagasse, MD*† The 1983 movie, The Right Stuff, was an adaptation of Tom Wolfe’s book by the same name that chronicled the Project Mercury astronauts selected by the National Aeronautics and Space Administration (NASA). Project Mercury began in 1959 and was the first manned space flight program in the United States (US). At that time, the Soviet Union was clearly leading the way in rocket technology and the US was not “measuring up.” The political mandate of competing against the Soviet Union in the “space race” seemed doomed to failure given the expense of such an endeavor and our obvious technology deficits. The first human space flight occurred on April 12, 1961, when cosmonaut Yuri Gagarin orbited the earth aboard a Soviet spacecraft. Fortunately, a determined group of astronauts, dubbed the Mercury Seven, brought the “right stuff” to the NASA program and the United States became the second nation to achieve manned space flight with the suborbital flight of astronaut Alan Shepard on May 5, 1961. Less than 1 yr later, the first US orbital flight was achieved by John Glenn, and established the US as a true competitor in space. As of this year, human spaceflight missions have been conducted by the Soviet Union, the US, Russia, the People’s Republic of China, and by a private US space flight company. I mention this brief history of the early years of the Project Mercury space program because I believe there are many parallels between the NASA quest for manned space flight and the Department of Veterans Affairs (VA) quest for quality perioperative care as described by Bishop et al. in this issue of Anesthesia & Analgesia. During the mid-to-late 1980s, the VA came under a great deal of public scrutiny over the quality of surgical care in their 133 hospitals. At issue were the operative mortality rates in the VA hospitals and the perception in Congress that the VA was not measuring up to the private sector. To address the gap, Congress mandated the VA to report risk-adjusted surgical outcomes annually, and compare their outcomes to national averages. Unfortunately, perioperative performance measurement technology had not advanced to the point where there were risk-adjusted national averages. Still, the VA was able to exhibit the right stuff and develop the National Surgical Quality Improvement Program (NSQIP) that includes risk adjustment models for 30-day morbidity and mortality after major surgery in 8 surgical subspecialties and for all operations combined. Preoperative patient characteristics used in these models include demographics, symptoms, physical findings, comorbidities unrelated to the reason for surgery, preoperative laboratory values, and ASA physical status which, with all of its strengths and weaknesses, is a major predictive factor. But, this modeling did not come without a price. The cost of data collection and analysis has been quoted at approximately $38 per case. The VA database is expanding by approximately 100,000 cases annually and currently has more than 1 million cases. Thus, the cost to date has been more than $38 million, yet private sector hospitals are still lining up to participate as they expand this project beyond the VA hospitals under the auspices of the American College of Surgeons (ACS). In ACS NSQIP, each hospital From the *Department of Anesthesiology, Montefiore Medical Center, Bronx, New York; and †The Albert Einstein College of Medicine, Bronx, New York. Accepted for publication July 24, 2008. Reprints will not be available from the author. Address correspondence to Robert S. Lagasse, MD, Department of Anesthesiology, Weiler Division of Montefiore Medical Center, 1825 Eastchester Rd., Bronx, NY 10461. Address e-mail to boblagasse@yahoo.com. Copyright © 2008 International Anesthesia Research Society DOI: 10.1213/ane.0b013e31818af90a