Exclusion from SIR Analysis: Are low volume hospitals getting a pass?
Exclusion from SIR Analysis: Are Low Volume Hospitals Getting a Pass?
Background: In 2012, the Centers for Medicare and Medicaid Services (CMS) made it mandatory for all hospitals participating in the Inpatient Prospective Payment System (IPPS) to report surgical site infections (SSI) associated with qualifying abdominal hysterectomy (HYST) and colon procedures (COLO) to the National Healthcare Safety Network (NHSN). These data are then made available to the public on Medicare's Hospital Compare website. However, if a hospital does not perform enough procedures for the reporting period to calculate a valid standardized infection ratio (SIR), it is excluded from reporting. The objective of this study was to propose an alternate way to report a SIR for these low volume hospitals.
Methods: 2012 and 2013 COLO and HYST SIR were calculated using the “SIR - In-plan Complex AR SSI data by procedure” report in NHSN. Only low volume facilities (3 for COLO; 6 for HYST) in our system were included in this analysis. Low volume was defined as having at least one calendar year where the expected number of SSI for at least one of the surgery categories was less than 1, not allowing for a valid SIR to be calculated.
Results: See Figures 1 & 2. By analyzing 2 years COLO data together for each of our 3 low volume hospitals, we are able to calculate a valid SIR. By doing the same for our 6 low volume HYST hospitals, we were able to calculate valid SIR for 3 of them. The remaining 3 still do not have enough procedures to have an expected number of SSI greater than 1.
Conclusion: Combining data across years may allow SIR calculation for low volume hospitals, allowing for inclusion of these facilities in public reporting. For very low volume facilities, other alternative methods to evaluate performance may be needed.
H. M. Babcock, None