The Importance and Challenges of a Specialty-Specific National Surgical Quality Improvement Program for Head and Neck Surgery

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was started by an act of the United States Congress in an attempt to decrease excessive mortality among patients within the Veterans Health Administration system. Currently, more than 200 hospitals participate in the ACSNSQIP system. The focus of the program has beenmainly on general surgery and vascular surgery procedures. A key part of ACS-NSQIP has been the recognition of the need for adjustment for patient-specific illness severity. Approximately 10years ago, the leadership at theACS recognized several problemswith ACS-NSQIP that they believed potentially limited thevalue andutility of theprogram.Toaddress these problems, they set about to change the structure and format of ACS-NSQIP. In 2008, the Measurement and Evaluation Committee of ACS published their recommendations for a newand improvedACS-NSQIP.1 Among their 8 recommendations was that the NSQIP develop a new, specialtyspecific approach in its outcomes registries, recognizing that to achieve this goal would require participation by specialty societies and the leadership within these societies. In this issue of JAMA Otolaryngology–Head & Neck Surgery, Lewis et al2 present the development and feasibility of a head and neck oncology–specific NSQIP module. This is a timely and important topic, especially in the context of ongoing efforts to implement value-based payment fundingmodelsandgreaterattentiontomeasurementandreportingofquality performance inmany jurisdictions inNorthAmerica.With the goal in mind of improving the delivery of health care by head and neck surgical oncologists, Lewis et al make an admirable start toward the development of a specialty-specific NSQIP. In the process, they modify existing ACS-NSQIP definitions to better suit the head and neck oncology patient and specialty. We outline some of the strengths and weaknesses of this approachandthechallenges to implementationofa specialty-specific module developed within NSQIP. Lewis et al2 identify 3main strengths of their process. The first is inclusion of amultidisciplinary teamof head and neck surgeons, plastic surgeons, a speech pathologist, and the institutionalACS-NSQIP surgeon to identify preoperative, intraoperative,andpostoperativevariablesspecific toheadandneck cancer andablative surgery requiring reconstruction.The second important strength is the inclusion of functional outcomes in the data collection process. All head and neck cancer physicians and patients understand the importance of capturing information related to the functional limitations associatedwith treatment.Andyet this information is rarely captured incancer registries andadministrativedatabases.A third strength is the identification of the operating surgeons to allow for individualized surgeon performance assessment. The authors also acknowledge a few weaknesses of their approach.2 The first is that several of the new functional variables have not yet been validated in the literature. A second weakness is the inability to capture pretreatment functional status because patients identified for inclusion in NSQIP are identifiedpostoperatively throughCurrent Procedural Terminology codes. The lack of pretreatment functional status decreasesmeaningful conclusions regarding the effects of treatmentbasedonthestudyofposttreatment functionaloutcomes alone. The flexibility of the NSQIP platform and its ability to incorporate newvariables andmodules is critical to the success of the subspecialty-specific NSQIP modules. The developmentof surgeon-and institution-specific report cards is apowerful quality improvement instrument andmust be included in futureNSQIPmodules. For example, surgeonandpathologist-level report cards were implemented in 3 of the 14 regions in Ontario, Canada. These report cards provide surgeons and pathologistswith positivemargin and lymphnode retrieval rates in prostate and colorectal cancer. In addition, all surgeons inOntario receive provider-level performanceon access to care for their patients, and their performance is compared with hospital, regional, and provincial peers. The preliminary results are promising. In an earlier study by Lewis et al,3 this sameapproachwas analyzed, and favorable improvement results were reported. Unfortunately, there arehigh costs associatedwith the retrievalandreportingofqualitydata throughNSQIP.Thesecosts include the training and auditing of surgical clinical reviewers.Unfortunately, not all centers can afford such training and auditing, andtheverycenters thatcannotmaybe theoneswith the higher-than-expected complication rates and lower quality of care. The contrary argument to the significant resource investment is that higher quality of care is safer, more effective, and ultimately more cost-efficient. The study by Lewis et al2 was performed at a highvolume tertiary institution and, as the authors note, the applicability of this type of data collection to smaller centers is unknown.Furthermore, evenwith themost sophisticated risk adjustment techniques, there are inherent and unmeasured differences between patients and across centers that will not orcannotbe included in themodel.TheNSQIP iswell equipped to drive quality improvement locally, but regionally, statewide, and nationally, this approach becomes challenging due Related article page 321 Research Original Investigation The Head and Neck–Reconstructive Surgery NSQIP