I would like to respond to the recent Point/Counterpoint column on the Surgical Care Improvement Project ("Are SCIP recommendations effective in improving quality of care?" January 2014, p. 3). Without dispute, the primary goal of SCIP to reduce the morbidity and mortality from surgical infections by 25% by 2010 was not achieved. Where SCIP succeeded instead was in improving the quality of hospital documentation, through efforts often motivated by pay-for-performance incentives. Ironically, SCIP may result in increased rates of infection nationally, by capturing wound infections that would otherwise not have been reported.
SCIP generated numerous studies in the literature with unclear and conflicting results. The majority are single institution studies, and suggest either marginal improvement, or no reduction, in the rates of wound infection after adherence to SCIP measures. Many of these studies are unpowered or suffer from study design flaws that limit their ability to show a difference. The confusing state of the literature is reflected by the debate published in the January issue of Surgery News, in which two debaters highlighted different parts of the same study and came to opposite conclusions. A handful of reports are from single programs in which extraordinary investments of staff, resources, and time resulted in significant reductions in wound infections, but these heroic local efforts are likely neither sustainable nor generalizable nationally.
A long-standing tradition in surgery has been to analyze undesirable patient outcomes through the morbidity and mortality conference, to understand the contributing causes of the event and what might be done differently in the future. Applying that tradition here, what did we learn from the significant national effort to comply with SCIP? The literature strongly suggests that patients who have a greater number of comorbid conditions, who are in a higher ASA class, and who underwent colon or more complex procedures, were less likely to have adherence to SCIP, and more likely to suffer a surgical site infection. Others have suggested that the principal unrealized benefit of SCIP could have been for patients with exclusion criteria, which precluded their participation in the program. Focusing infection prevention practices upon these patient populations in the future might be worthwhile.
Why did SCIP fail? Perhaps greater initial input by surgeons into the selection of SCIP measures would have been helpful. Some of the measures were more successful than others. The data for SCIP Inf-2 (giving the correct antibiotics) are perhaps the strongest, as they also makes the most clinical sense. On the other hand, SCIP Inf-3 (stopping antibiotics within 24 hrs) could reasonably have been expected to reduce antimicrobial resistance, decrease the incidence of medication side effects such as nephrotoxicity, and save costs, but on reflection, stopping antibiotics earlier in uncertain situations should not have been expected to reduce infections.
And then there is the fraud in the scientific literature. Only years after SCIP was launched was the evidence upon which the initial beta-blocker recommendations were made recognized to be fraudulent. The Dutch researcher has been accused of scientific misconduct, and independent investigations have concluded that more patients were harmed and died than benefitted, by complying with the beta-blocker recommendations in this study.
We should recognize that the key intent of SCIP remains unfulfilled. Wound infections continue to result in prolonged hospital stays and increased health care costs worldwide. In the interest of patient safety, surgeons should consider taking the next step forward to transform the well-intended SCIP effort. We know all too well that improving clinical care is quite difficult, and policy makers will need our insights to reflect upon the valuable lessons learned to reduce surgical infections. Until then, caution is advised for federal efforts that seek to incorporate SCIP into value-based purchasing initiatives. Those attempts are likely premature until better data are available that withstands the test of time.
John Maa, MD, FACS
President, Northern California Chapter of the American College of Surgeons