American College of Surgeons and Blue Cross Blue Shield of Michigan Partner toStudy Outcomes for General and Vascular Surgery Patients

CHICAGO, Aug. 18 -- Fifteen of the largest hospitals in the state of Michigan will soon be participating in a ground-breaking program to evaluate the results of the general and vascular surgery procedures performed in their institutions. Participating hospitals will submit surgical patients’ outcomes data to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and make use of its data collection and analysis instruments, which have a proven track record in the Veteran’s Affairs (VA) surgical care system. This joint collaboration between the ACS and Blue Cross Blue Shield of Michigan (BCBSM) and its HMO affiliate Blue Care Network represents a pioneering effort between a national medical organization and a health plan to evaluate and improve the quality of surgical care, while ultimately reducing health care delivery costs.

Escalating health care costs have adversely affected the bottom line of manufacturing companies in the industrialized state of Michigan, making it a good proving ground for this endeavor. The goal of the ACS NSQIP program is to reduce surgical morbidity (infection or illness related to a surgical procedure) and surgical mortality (death related to a surgical procedure), and to provide a firm foundation for surgeons to apply what is known as the “best scientific evidence” to the practice of surgery. When adverse effects from surgical procedures are reduced and/or eliminated, a reduction in health care costs follows. By working with ACS NSQIP in its surgical quality improvement endeavors, BCBSM hopes to improve health care quality in Michigan while reducing costs.

ACS NSQIP is a national validated program that was created to measure and enhance the care of surgical patients. The program is outcomes-based, meaning it measures the actual results of operations. It is also risk-adjusted, which means it compensates for differences among patients, such as age and overall health status, which would otherwise affect health care outcomes. NSQIP, now referred to as the ACS NSQIP, has been successfully used in the VA health care system for over a decade. “The original National Surgical Quality Improvement Program was initiated 11 years ago by the Veterans Health Administration (VHA) to measure the incidence of operative morbidity and mortality in VA hospitals,” according to R. Scott Jones, MD, FACS, director of the ACS Division of Research and Optimal Patient Care. “After the program was implemented in 128 VA hospitals, surgical mortality decreased by 27 percent and morbidity decreased by 45 percent,” Dr. Jones reported.

In 2001, a grant from the Agency for Healthcare Research and Quality was awarded to the ACS and the VA for collaborative implementation of the NSQIP in private sector hospitals. A three-year study followed, which collected data from nearly 100,000 surgical cases collected from 18 private sector hospitals. “The results of the study have shown that the program has been successfully implemented in these hospitals and that the NSQIP methodology works well in the private sector,” Dr. Jones explained.

The introduction of ACS NSQIP in the state of Michigan represents a new approach to using this pre-existing quality measurement program: participating hospitals are all in one state and are working with each other and a health plan, BCBSM, to identify and act on opportunities for quality improvement. Moreover, all institutions will be enrolled in the program on a “pay for participation” basis rather than the common “pay for performance” basis. This arrangement means that they will receive financial support from BCBSM for a substantial proportion of the data collection costs if they are actively contributing data to the ACS NSQIP registry and participating in the collaborative quality improvement effort.

In the ’pay for participation’ arrangement, a large proportion of the data collection costs are distributed equally to the participating hospitals in recognition of their commitment to surgical quality. Individual hospital results are not disclosed to BCBSM, but overall results are monitored carefully and are expected to show a significant improvement over time. “In contrast to the ’pay for performance’ model, the ’pay for participation’ approach produces no winners or losers among hospitals. The winners are the patients,” according to Darrell A. Campbell, Jr. MD, FACS, Professor of Surgery and Chief of Staff at the University of Michigan Health System, Ann Arbor, and Chair of the ACS NSQIP Advisory Committee. “ACS NSQIP is the quality infrastructure which, for the first time, allows this strategy,” says Dr. Campbell, who led the University of Michigan’s participation in the national pilot program that implemented NSQIP among non-VA hospitals. According to BCBSM, trained nurse reviewers will collect information from a patient sample undergoing general or vascular surgery procedures for electronic submission through the ACS NSQIP Web site. Reviewers will collect data about patient characteristics as well as outcomes including 21 different potential complications for a wide range of general and vascular surgery procedures such as cholecystectomy (gall bladder removal) and carotid endarterectomy (surgical removal of blockages from blood vessels in the neck).

Michigan hospitals will begin reporting their data to ACS NSQIP this fall, Dr. Campbell said. Aggregate data on the impact of the project will be made available to BCBSM and provided in public reports about the project. However, the individual hospital data will be available only to the participating hospital and its surgeons for quality assessment and improvement purposes.

ACS NSQIP is one of three health care quality improvement initiatives currently under way through BCBSM, according to David Share, MD, MPH, Clinical Director of the BCBSM Center for Health Care Quality and Evaluative Studies. In addition to the ACS NSQIP study of outcomes of general and vascular surgical procedures, Dr. Share said, BCBSM has also funded statewide surgical outcome registries and quality improvement programs for cardiac surgery ( in collaboration with the Michigan Society of Thoracic and Cardiovascular Surgeons), and bariatric surgery (inviting all hospitals that perform the procedure in the state to participate).

“These pay for participation, evidence-based, collaborative surgery quality improvement programs are modeled after the extraordinary success that BCBSM has achieved through its support of the BCBSM Cardiovascular Consortium Angioplasty Continuous Quality Improvement Project (BMC2),” said Dr. Share, who is co-investigator on the BMC2 project. “This project has enhanced the safety and care of patients undergoing artery-opening angioplasty procedures across the state while saving more than $8 million in medical care costs annually,” he added.

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 66,000 members and it is the largest organization of surgeons in the world.

Blue Cross Blue Shield of Michigan, a nonprofit corporation, provides health care benefits to just over 4.7 million members through a variety of plans: Traditional Blue Cross Blue Shield; Blue Preferred, Community Blue and Healthy Blue PPOs; Blue Choice Point of Service; Blue Care Network HMO, and Blue HSASM plans compatible with health savings accounts. Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

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Sally Garneski

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American College of Surgeons

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