Invited Commentary
June 18, 2024
The American College of Surgeons Approach to Public Reporting
Anoosha Moturu, Patricia L. Turner, Clifford Y. Ko
JAMA Surg. Published online June 18, 2024. doi:10.1001/jamasurg.2024.1591
We commend Diaz et al1 for studying the limitations of the Centers for Medicare & Medicaid Services (CMS) Star Rating System for reporting surgical quality and agree a need exists to improve publicly reported hospital quality in surgery.
Evaluating surgical quality is difficult for many reasons. For one, the source of data most used for evaluating quality is suboptimal. The CMS and other benchmarking organizations use claims data (also known as administrative or billing data) for many of their metrics, which has been shown to be inferior to clinical data for reporting surgical outcomes.2 Furthermore, using claims rather than clinical data for risk adjustment to control for patient comorbidities similarly has lesser accuracy.3 In addition, regardless of data source, several surgical outcomes cannot be reliably or validly measured,4 and hence different types (eg, process or composite) of metrics are needed.
What would better publicly reported surgical quality look like? The American College of Surgeons (ACS) has been evaluating surgical quality for more than 100 years. The ACS is building on lessons from its accreditation programs and measure-development experience to offer a public-reporting solution.
Following the Donabedian Quality Model, all ACS quality programs audit hospitals for a set of defined evidence-based structures and processes that directly and/or indirectly yield better outcomes. In trauma for example, the ACS conducts site visits to evaluate and verify that US level 1 trauma centers are compliant with more than 200 structural and process-based trauma standards. When evaluated, these accredited trauma centers have better outcomes.5 Similarly, hospitals accredited by the ACS Bariatric Surgery Quality Program have demonstrably lower complications, mortality, and costs.6
Thus, for an initial path forward for publicly reported surgical quality, the ACS will report hospitals that are formally accredited by an ACS quality program. Currently, more than 2300 hospitals in the US have been accredited across a spectrum of surgery-related diseases and settings (eg, urban vs rural, teaching vs nonteaching).
As a next possible step, the ACS recently developed a new type of performance measure, more specifically a focused-composite programmatic measure.7 An example is the geriatric measure recently developed by the ACS, which includes structural (staffing and roles specific to geriatrics), processes (frailty assessments), and outcomes (length of stay). The CMS Measures Under Consideration vetting process noted that the validity, feasibility, and usefulness of this programmatic measure were uniquely advantageous compared with singular outcome measures. The geriatric measure is currently under consideration for the CMS 2024 Proposed Rule.
As highlighted by Diaz et al,1 limited availability of good, accurate, and meaningful information for publicly reported surgical quality is noticeable. The ACS is addressing this deficiency by developing a public reporting site and compiling metrics for the public, based on lessons from decades of leading surgical quality of care measurement, standards development, accreditation, and improvement.
