National Surgical Quality Databases and Clinical Registries

ACS-NSQIP is a leading, nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. Mass General, through the Codman Center, has participated in this program since 2002. Highly trained nurse reviewers, using standardized definitions, gather as many as 134 data points on a sample of patients who have general, vascular or plastics surgical procedures. Patient outcomes are assessed for 30 post-operative days. More than 28,000 cases have been collected to date.

Procedure-targeted data collection focuses on high-volume, high-risk procedures and has enabled Mass General to compare its performance to other institutions, as well as improve the quality of our surgical care. Twice a year, Mass General receives nationally benchmarked and risk-adjusted results from ACS-NSQIP, such as data on 30-day morbidity and mortality, surgical site infection, pneumonia and cardiac complications. There is also the ability to run real-time analysis of raw results. The outcome data is used to determine areas that need improvement. Reducing complications leads to shorter length of hospital stays, lower costs of care, improved mortality rates and improved patient experience of care. The data also provides a rich resource to support research.

Participation in the MBSA-QIP is required to be a fully-accredited bariatric surgery program. The Mass General Bariatric Surgery Program has participated in the registry since 2007 and uses the data to support continuous quality improvement. Data from all bariatric surgeries are reported to the database, including risk, procedure and outcome data points which are abstracted from the medical record by trained and audited nurse reviewers. Longitudinal data is collected, including morbidity, mortality and reduction in weight and weight-related comorbidities such as high blood pressure and diabetes. More than 1,400 cases have been collected to date.

Participation in this registry includes capturing 100% of cardiac procedures identified from operative schedules. Risk, procedure and 30-day outcome data points are abstracted from the medical record by trained and audited nurse reviewers. Benchmarked reports are distributed quarterly, including volumes, rates and risk-adjusted morbidity and mortality. In addition, STS reports a composite quality score. STS public reporting online enables voluntary public reporting on heart bypass surgery performance.

This registry reports outcomes from all general thoracic surgery cases identified from operative schedules. Risk, procedure and 30-day outcome data points are abstracted from the medical record by trained nurse reviewers. Selected outcomes are risk-adjusted by the STS and reported every six months. The results are used for continuous quality improvement.

The Mass-DAC registry captures the same cardiac cases as are reported to STS. Risk, procedure and outcome data points are abstracted from the medical record by trained and audited nurse reviewers. Risk-adjusted, 30-day coronary artery bypass graft (CABG) mortality data is reported annually at both the hospital and physician level. CABG mortality data is publicly reported on the Department of Public Health website and is mandated by law for cardiac surgery program certification.

The TRACS registry captures 100 percent of patients admitted to the Mass General Burns Center. Data elements include demographics, injury, diagnosis, operating room cases, resource utilization, outcome and quality assurance. These elements are collected by trained clinical reviewers. The data is used for certification and internally for quality improvement initiatives.

The NTDB is the largest aggregation of trauma registry data assembled in the United States, capturing 100 percent of trauma cases. Data includes volume, acuity, age, length of stay, average ICU length of stay, ventilator days and mortality. Data is not currently risk-adjusted. Hospitals can use the data to compare outcomes to like facilities in size and level of trauma activity.

SRTR supports the ongoing evaluation of solid organ transplantation in the United States and aims to inform transplant programs, organ procurement organizations, policy makers, transplant clinicians, transplant recipients, organ donors and donor families and the general public about the current state of solid organ transplantation. SRTR also helps facilitate transplant research by providing access to data for qualified researchers. At Mass General, this registry captures 100 percent of liver, kidney, pancreas, lung and heart transplants. Organ transplant statistics include demographics, risk variables, volume, waitlist time and mortality on waitlist, patient mortality after transplant and graft survival. Data is reported every six months by Mass General’s transplant program and is risk-adjusted for expected survival. Results are publicly reported on the SRTR website.

The SVS-PSO improves patient safety and the quality of health care delivery by providing web-based collection, aggregation and analysis of clinical data submitted in registry format for all patients undergoing specific vascular treatments, such as carotid endarterectomy, lower extremity bypass, abdominal aortic aneurysm repair (open and endovascular), carotid artery stenting and peripheral vascular intervention. VSGNE generates reports twice per year that show trends over time, volumes, process characteristics and selected in-hospital outcomes. Reports are region-based, center-based or surgeon-based, and many are risk-adjusted. The results are used to support quality improvement initiatives.