Surgical Care And Outcomes Assessment Program Research Articles

Surgical Care and Outcomes Assessment Program (SCOAP): A Nuanced, Flexible Platform for Colorectal Surgical Research.

The Surgical Care and Outcomes Assessment Program (SCOAP) is a surgeon-led quality improvement (QI) initiative developed in Washington State to track and reduce variability in surgical care. It has developed into a collaboration of over two-thirds of the hospitals in the state, who share data and receive regular benchmarking reports. Data are abstracted at each site by trained abstractors. While there has some overlap with other national QI databases, the data captured by SCOAP has clinical nuances that make it pragmatic for studying surgical care. We review the unique properties of SCOAP and offer some examples of its novel applications.

Communication Training, Adverse Events, and Quality Measures: 2 Retrospective Database Analyses in Washington State Hospitals.

Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013). Using administrative data from Washington State's Comprehensive Hospital Abstract Reporting System (CHARS) and clinical registry data from the Surgical Care and Outcomes Assessment Program (SCOAP), we compared proportions of AEs and quality measures between HealthPact (n = 4) and non-HealthPact (n = 93-CHARS; n = 48-SCOAP) participating hospitals. Risk ratios enabled comparisons between the 2 groups. Multivariable logistic regression enabled investigation of the association between training and the frequency of AEs. Approximately 9.4% (CHARS) and 7.7% (SCOAP) of unique patients experienced 1 AE or greater. In CHARS, the odds of a patient experiencing an AE in a HealthPact hospital were initially (pretraining) higher than in a non-HealthPact hospital (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10-1.17), lower in transition (OR, 0.80; 95% CI, 0.76-0.83) and posttraining (OR, 0.72; 95% CI, 0.69-0.75) periods. In SCOAP, ORs were consistently lower in HealthPact hospitals: pretraining (OR, 0.87; 95% CI, 0.80-0.95), transition (OR, 0.75; 95% CI, 0.70-0.81), and posttraining (OR, 0.63; 95% CI, 0.58-0.68). The proportion of at-risk patients that experienced each individual AE was low (<1%) throughout. Adherence to quality measures was high. Interprofessional communication training is an area of intense activity nationwide. A broad-based training initiative may play a role in mitigating AEs.

Effects of arginine-based immunonutrition on inpatient total costs and hospitalization outcomes for patients undergoing colorectal surgery.

The aim of this study was to assess the effects of an arginine-based immunonutrition intervention for patients undergoing elective colorectal surgery on postsurgical utilization and cost outcomes. This analysis was based on data from two Washington State databases: Surgical Care and Outcomes Assessment Program (SCOAP) linked to the Comprehensive Hospital Abstract Reporting System (CHARS). The sample (N=722) comprises adult patients who underwent elective colorectal surgery with anastomosis in a Washington State hospital that participated in the Strong for Surgery (S4S) initiative between January 1, 2012, and December 31, 2013. A generalized linear model was used to predict the outcomes, adjusting for demographic characteristics and patient health conditions within a multivariate regression framework. Findings from this study demonstrated significantly fewer readmissions and hospital days for the intervention group during the 180d after index hospitalization. Clinical benefits included decreased risk for infections and venous thromboembolism. There was a similar pattern toward lower total costs in the immunonutrition patient group; however, these were not statistically different compared with the control group at any time point. Savings in the immunonutrition group were substantial-mean total costs per patient were less by ∼$2500 at index hospitalization, $3500 less through 30d of follow-up, and $5300 less over 180d compared with the control group. These findings suggest that arginine-based immunonutrition should be thoroughly evaluated for incorporation into clinical practice for patients undergoing elective surgery. Moreover, there is a need to assess the effects of the intervention in other hospitals both within and outside Washington.

Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care and Outcomes Assessment Program Comparative Effectiveness Research Translation Network Collaborative

Randomized trials have found that alvimopan hastens return of bowel function and reduces length of stay (LOS) by 1 day among patients undergoing colorectal surgery. However, its effectiveness in routine clinical practice and its impact on hospital costs remain uncertain. We performed a retrospective cohort study of patients undergoing elective colorectal surgery in Washington state (2009 to 2013) using data from a clinical registry (Surgical Care andOutcomes Assessment Program) linked to a statewide hospital discharge database (Comprehensive Hospital Abstract Reporting System). We used generalized estimating equations to evaluate the relationship between alvimopan and outcomes, and adjusted for patient, operative, and management characteristics. Hospital charges were converted to costs using hospital-specific charge to cost ratios, and were adjusted for inflation to 2013 US dollars. Among 14,781 patients undergoing elective colorectal surgery at 51 hospitals, 1,615 (11%) received alvimopan. Patients who received alvimopan had a LOS that was 1.8 days shorter (p< 0.01) and costs that were $2,017 lower (p < 0.01) compared with those who did not receive alvimopan. After adjustment, LOS was 0.9 days shorter (p < 0.01), and hospital costs were $636 lower (p= 0.02) among those receiving alvimopan compared with those who did not. When used in routine clinical practice, alvimopan was associated with a shorter LOS and limited but significant hospital cost savings. Both efficacy and effectiveness data support the use of alvimopan in routine clinical practice, and its use could be measured as a marker of higher quality care.

Intraoperative Neuromonitoring in Spine Surgery and New Neurologic Events: A Report from the Surgical Care and Outcomes Assessment Program (SCOAP)

Intraoperative neuromonitoring (INM) in spine surgery has been suggested to decrease the risk of neurological events but its effectiveness in common practice has not been established.

Automating data abstraction in a quality improvement platform for surgical and interventional procedures.

Objective:This paper describes a text processing system designed to automate the manual data abstraction process in a quality improvement (QI) program. The Surgical Care and Outcomes Assessment Program (SCOAP) is a clinician-led, statewide performance benchmarking QI platform for surgical and interventional procedures. The data elements abstracted as part of this program cover a wide range of clinical information from patient medical history to details of surgical interventions.Methods:Statistical and rule-based extractors were developed to automatically abstract data elements. A preprocessing pipeline was created to chunk free-text notes into its sections, sentences, and tokens. The information extracted in this preprocessing step was used by the statistical and rule-based extractors as features.Findings:Performance results for 25 extractors (14 statistical, 11 rule based) are presented. The average f1-scores for 11 rule-based extractors and 14 statistical extractors are 0.785 (min=0.576,max=0.931,std-dev=0.113) and 0.812 (min=0.571,max=0.993,std-dev=0.135) respectively.Discussion:Our error analysis revealed that most extraction errors were due either to data imbalance in the data set or the way the gold standard had been created.Conclusion:As future work, more experiments will be conducted with a more comprehensive data set from multiple institutions contributing to the QI project.

Availability of Structured and Unstructured Clinical Data for Comparative Effectiveness Research and Quality Improvement: A Multi-Site Assessment

Introduction:A key attribute of a learning health care system is the ability to collect and analyze routinely collected clinical data in order to quickly generate new clinical evidence, and to monitor the quality of the care provided. To achieve this vision, clinical data must be easy to extract and stored in computer readable formats. We conducted this study across multiple organizations to assess the availability of such data specifically for comparative effectiveness research (CER) and quality improvement (QI) on surgical procedures.Setting:This study was conducted in the context of the data needed for the already established Surgical Care and Outcomes Assessment Program (SCOAP), a clinician-led, performance benchmarking, and QI registry for surgical and interventional procedures in Washington State.Methods:We selected six hospitals, managed by two Health Information Technology (HIT) groups, and assessed the ease of automated extraction of the data required to complete the SCOAP data collection forms. Each data element was classified as easy, moderate, or complex to extract.Results:Overall, a significant proportion of the data required to automatically complete the SCOAP forms was not stored in structured computer-readable formats, with more than 75 percent of all data elements being classified as moderately complex or complex to extract. The distribution differed significantly between the health care systems studied.Conclusions:Although highly desirable, a learning health care system does not automatically emerge from the implementation of electronic health records (EHRs). Innovative methods to improve the structured capture of clinical data are needed to facilitate the use of routinely collected clinical data for patient phenotyping.

PCV25 - Building the infrastructure for conducting pragmatic trials in a learning health care system

To describe methods used and successes realized in building the infrastructure to conduct pragmatic clinical trials of comparative effectiveness research (CER) in Washington State’s Learning Healthcare System - the Comparative Effectiveness Research Translation Network (CERTAIN). Leveraging the infrastructure of the Surgical Care and Outcomes Assessment Program (SCOAP), a statewide coordinated quality improvement program that tracks surgical outcomes in hospitals, we created an infrastructure for conducting CER/PCOR. We are using the CERTAIN network to conduct a pragmatic clinical trial – a multi-site, prospective, observational cohort study of patients in community settings with peripheral artery disease (PAD) treated with open surgical, endovascular, or conservatively managed care. Clinical and patient-reported outcomes (PRO) are collected at baseline, 30-days, 6- and 12-months post intervention. The primary outcome is the change in scores on the Walking Impairment Questionnaire. The SCOAP Medical Director engaged PAD-treating vascular surgeons, interventional radiologists and cardiologists. Study staff educated all institutional review boards about pragmatic trials. The SCOAP CERTAIN Survey Center administers all PRO surveys using a mode of administration of each patient’s choice (e.g. web-based, paper-pencil); and deploys vigorous follow-up contact algorithms to retain patients. Over 18-months, 15 sites have been engaged and are enrolling patients. Over 5500 medical records have been screened; 1016 patients (18%) with PAD identified. 415/1,016 (41%) met all inclusion criteria and received enrollment packets, 193 are actively participating, 14 have completed the study. Enrollment continues through September 2013. In companion work, CERTAIN Investigators developed their own ‘symptom’ instrument, informed by interviews with 11 patients; and are conducting a sub-study to compare scores on PRO instruments administered using various modes of administration. This CERTAIN PAD study illustrates the effort required to conduct a pragmatic trial. As the nation embraces the research paradigm of CER, Washington State’s Learning Healthcare System is modeling success.

Progress in the Diagnosis of Appendicitis

Studies suggest that computed tomography and ultrasonography can effectively diagnose and rule out appendicitis, safely reducing negative appendectomies (NAs); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community. Data were collected prospectively for consecutive appendectomy patients (age > 15 years) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiological, operative, and pathological reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted. Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, it was 15.4% (P < 0.001). This association was consistent for men (3% vs 10%, P < 0.001) and for women of reproductive age (6.9% vs 24.7%, P < 0.001). In a multivariate model adjusted for age, sex, and white blood cell count, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95% CI: 3.0-4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged. Patients who were not imaged during workup for suspected appendicitis had more than 3 times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked practice change.

Adoption of Laparoscopy for Elective Colorectal Resection: A Report from the Surgical Care and Outcomes Assessment Program

The purpose of this study was to evaluate the adoption of laparoscopic colon surgery and assess its impact in the community at large. The Surgical Care and Outcomes Assessment Program (SCOAP) is a quality improvement benchmarking initiative in the Northwest using medical record-based data. We evaluated the use of laparoscopy and a composite of adverse events (ie, death or clinical reintervention) for patients undergoing elective colorectal surgery at 48 hospitals from the 4th quarter of 2005 through 4th quarter of 2010. Of the 9,705 patients undergoing elective colorectal operations (mean age 60.6 ± 15.6 years; 55.2% women), 38.0% were performed laparoscopically (17.8% laparoscopic procedures converted to open). The use of laparoscopic procedures increased from 23.3% in 4th quarter of 2005 to 41.6% in 4th quarter of 2010 (trend during study period, p < 0.001). After adjustment (for age, sex, albumin levels, diabetes, body mass index, comorbidity index, cancer diagnosis, year, hospital bed size, and urban vs rural location), the risk of transfusions (odds ratio [OR] = 0.52; 95% CI, 0.39-0.7), wound infections (OR = 0.45; 95% CI, 0.34-0.61), and composite of adverse events (OR = 0.58; 95% CI, 0.43-0.79) were all significantly lower with laparoscopy. Within those hospitals that had been in SCOAP since 2006, hospitals where laparoscopy was most commonly used also had a substantial increase in the volume of all types of colon surgery (202 cases per hospital in 2010 from 112 cases per hospital in 2006, an 80.4% increase) and, in particular, the number of resections for noncancer diagnoses and right-sided pathology. The use of laparoscopic colorectal resection increased in the Northwest. Increased adoption of laparoscopic colectomies was associated with greater use of all types of colorectal surgery.

Routine Leak Testing in Colorectal Surgery in the Surgical Care and Outcomes Assessment Program

To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. Observational, prospectively designed cohort study. Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP). Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter. Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.

Creating a learning healthcare system in surgery: Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) at 5 years

There are increasing efforts towards improving the quality and safety of surgical care while decreasing the costs. In Washington state, there has been a regional and unique approach to surgical quality improvement. The development of the Surgical Care and Outcomes Assessment Program (SCOAP) was first described 5 years ago. SCOAP is a peer-to-peer collaborative that engages surgeons to determine the many process of care metrics that go into a "perfect" operation, track on risk adjusted outcomes that are specific to a given operation, and create interventions to correct under performance in both the use of these process measures and outcomes. SCOAP is a thematic departure from report card oriented QI. SCOAP builds off the collaboration and trust of the surgical community and strives for quality improvement by having peers change behaviors of one another. We provide, here, the progress of the SCOAP initiative and highlight its achievements and challenges.

The use and outcomes of laparoscopic colorectal resection: Surgical Care and Outcomes Assessment Program

Introduction Population-level assessments of the utility and safety of laparoscopic colorectal surgery have been limited by a lack of clinical granularity. The purpose of this study was to evaluate the use and outcomes of laparoscopic colorectal surgery using clinical data from a statewide population. Methods The Surgical Care and Outcomes Assessment Program (SCOAP) is a Washington State-based benchmarking quality improvement (QI) initiative based on clinical data. We evaluated the use of laparoscopy, adverse events [composite adverse event (CAE) = death or reintervention], rates of transfusion, and length of stay (LOS) for patients undergoing elective colorectal surgery at 42 hospitals (2005-2009). Results Of the 6,945 patients (age 60.8 ± 15.5 yrs; 55.4% women) 28.2 % were done laparoscopically (45.6% laparoscopic hand-assisted). Laparoscopic procedures increased from 16.6% in quarter 1 to 29.2% in quarter 16 (p-value The unadjusted rates of CAE and transfusions were lower in laparoscopic procedures (4.5% vs. 6.8%; 3.8% vs. 10.6%, respectively p-value for both Conclusions The use of laparoscopic colorectal resection has increased over time, especially among lower risk patients. In community practice, laparoscopy was associated with lower transfusion rates but similar risk-adjusted rates of the CAE.

Routine Provocative Leak Testing In Colorectal Surgery As A Quality Improvement Metric

Introduction: The value of provocative testing of colorectal anastomoses to reduce morbidity and mortality has yet to be determined. Part of the challenge of determining its use as a quality improvement (QI) metric is that leak testing at the time of operation can be done to screen for leak as well as to confirm a suspected leak. If used for confirmation of a suspected leak then leak testing might actually appear to be associated with increased risk of leak. Methods: The Surgical Care and Outcomes Assessment Program (SCOAP) is a Washington State QI benchmarking tool based on chart-abstracted process of care and risk-adjusted outcomes data.

Negative Appendectomy and Imaging Accuracy in the Washington State Surgical Care and Outcomes Assessment Program

To evaluate negative appendectomy (NA) and the relationship of NA and computed tomography (CT) and/or ultrasound (US). SUMMARY BACKGROUND INFORMATION: NA may be influenced by the use and accuracy of preoperative CT/US. The Surgical Care and Outcomes Assessment Program (SCOAP) gathers chart-abstracted process of care data (such as CT/US accuracy) for general surgical procedures (including appendectomy) at most Washington State hospitals. We determined the prevalence of NA and CT/US concordance at the 15 SCOAP hospitals with >50 consecutive patients undergoing appendectomy (2006-2007). The number of patients who underwent urgent appendectomies was 3540. The percentage of patients who had imaging (CT-91%) was 86% (women-89%, men-83%). The use of imaging ranged across hospitals from 56% to 97%. There was 91% agreement between imaging and pathology report findings (92.3%-CT and 82.4%-US). The overall rate of NA was 6% (women-8%, men-4%). The prevalence of NA was 9.8% among patients having no imaging, 8.1% among those having an US, and 4.5% in those having a CT. Among patients with NA, CT/US was obtained in 75%; correct in 10% and incorrect or ambiguous in 65%. Higher rates of NA were correlated with lower rates of CT/US concordance (r = -0.57). There was no significant difference in rates of perforation between those with (17%) and without (15%) imaging (P = 0.2). There were significant increases in the use of CT/US and decreases in NA over the time period (P < 0.01). The prevalence of NA at SCOAP hospitals decreased significantly. Variation in NA between hospitals was linked closely to CT/US accuracy suggesting CT/US accuracy should be considered a measure of quality in the care of patients with presumed appendicitis.