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Original Investigation |

Improved Outcomes Associated With a Revised Quality Measure for Continuing Perioperative β-Blockade

Joshua S. Richman, MD, PhD1,2; Kamal M. F. Itani, MD3; Rhiannon J. Deierhoi, MPH1,2; William G. Henderson, MPH, PhD4,5; Mary T. Hawn, MD, MPH1,2
[+] Author Affiliations
1Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
2Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham
3Department of Surgery, Veterans Affairs Boston Health Care System, Boston University and Harvard Medical School, Boston, Massachusetts
4Denver Veterans Affairs Medical Center, Denver, Colorado
5University of Colorado Health Outcomes Program and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
JAMA Surg. 2014;149(10):1031-1037. doi:10.1001/jamasurg.2014.351.
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Importance  The Surgical Care Improvement Project perioperative β-blocker (BB) (SCIP-BB) continuation measure was revised in 2012 to incorporate inpatient BB continuation after discharge from the postanesthesia care unit.

Objective  To determine whether adherence to the original or revised SCIP-BB measure is associated with decreased adverse events.

Design, Setting, and Participants  Retrospective cohort study using national Veterans Affairs patient-level data on adherence to the original SCIP-BB measure and inpatient BB continuation for operations between July 2006 and August 2009.

Methods  Data for SCIP-BB measure adherence, inpatient BB continuation, and patient and procedure risk variables were used to estimate the associations between adherence to the original and revised SCIP-BB measures and outcomes of major adverse cardiovascular or cerebrovascular events (MACCEs) and their components of cardiovascular events, cerebrovascular events, and 30-day mortality. In addition to unadjusted estimates, propensity score matching and bootstrapping were used to estimate the associations and generate 95% CIs.

Main Outcomes and Measures  Major adverse cardiovascular or cerebrovascular events.

Results  Of 14 420 nonemergent operations with at least 2 postoperative inpatient days, 13 170 (91.3%) adhered to the original SCIP-BB measure, and 480 (3.3%) experienced a MACCE. Propensity score–matched analyses showed that adherence to the original SCIP-BB measure was not associated with MACCEs (odds ratio [OR], 1.00; 95% CI, 0.66-1.54) but was associated with increased cerebrovascular events (OR, 3.01; 95% CI, 1.00-10.07). Adherence to the revised SCIP-BB measure occurred in 11 597 (80.4%), and in matched analysis adherence was associated with decreased MACCEs (OR, 0.75; 95% CI, 0.57-0.95), cardiovascular events (OR, 0.66; 95% CI, 0.46-0.93), and 30-day mortality (OR, 0.74; 95% CI, 0.53-0.98). Adherence to the revised SCIP-BB measure was not associated with increased cerebrovascular events (OR, 1.22; 95% CI, 0.62-2.38).

Conclusions and Relevance  Adherence to the original SCIP-BB measure was associated with increased cerebrovascular events but not improved cardiovascular event outcomes. β-Blocker continuation consistent with the revised SCIP-BB measure is associated with reduced MACCEs, cardiovascular events, and 30-day mortality. These data provide a cautionary tale of implementing performance measures before they have been rigorously tested. Although the observed associations between adherence to the revised SCIP-BB measure and outcomes are promising, they should be evaluated in the postimplementation period.

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Figure 1.
Cohort Diagram and SCIP-BB Measure Criteria

BB indicates β-blocker; SCIP-BB, Surgical Care Improvement Project perioperative β-blocker; VA, Veterans Affairs; and VASQIP, VA Surgical Quality Improvement Program.

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Figure 2.
Unadjusted and Propensity Score–Matched Associations Between SCIP-BB Measure Adherence and Study Outcomes

MACCE indicates major adverse cardiovascular or cerebrovascular event; OR, odds ratio; PS, propensity score; and SCIP-BB, Surgical Care Improvement Project perioperative β-blocker.

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Figure 3.
Unadjusted and Propensity Score–Matched Associations Between SCIP-BB Measure Adherence and MACCEs Stratified by the RCRI

The tabulation of measure adherence by RCRI is summarized in the Table. MACCE indicates major adverse cardiovascular or cerebrovascular event; OR, odds ratio; PS, propensity score; RCRI, Revised Cardiac Risk Index; and SCIP-BB, Surgical Care Improvement Project perioperative β-blocker.

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