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Study of the benefit of prophylactic antibiotics prior to major surgery raises questions about pay for performance

A growing number of organizations are paying clinicians and hospitals for quality of care measures, such as achieving low rates of surgical site infections (SSIs). Timely administration of prophylactic antibiotics (PA) prior to major surgery is thought to reduce SSIs. However, a new study did not link timely PA to overall patient or hospital SSI rates. Although most of the patients did get PA prior to surgery, they did not receive it in a timely window (1 to 2 hours prior to surgical incision).

It may be that the metric for timely antibiotic administration is too restrictive to be able to discriminate between PA practices that significantly prevent SSIs, explain the researchers. They note that these data do not dispute the efficacy of timely PA administration for surgical procedures. However, they do challenge whether this measure appropriately guides patients to higher quality hospitals and whether those hospitals and physicians should be financially rewarded for performance.

The investigators studied SSI rates for 9,195 elective orthopedic, colon, and vascular procedures performed in 95 Department of Veterans Affairs hospitals. They compared patient and hospital data from the External Peer Review Program Surgical Care Improvement Project with matched data from the National Surgical Quality Improvement Program data. About 86 percent of patients received timely PA.

Overall, timely PA did not markedly contribute to overall patient or hospital SSI rates. In hospital-level analysis, hospital case volume and hospital case mix were much more important predictors of hospital SSI rate than the hospital's rate of timely PA. The study was supported in part by the Agency for Healthcare Research and Quality (HS13852).

More details are in "Association of timely administration of prophylactic antibiotics for major surgical procedures and surgical site infection," by Mary T. Hawn, M.D., M.P.H., F.A.C.S., Kamal M. Itani, M.D., F.A.C.S., Stephen H. Gray, M.D., and others, in the May 2008 Journal of the American College of Surgeons 206, pp. 814-821.

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