Surgical site infections (SSI) following spine instrumentation surgery is associated with increased morbidity and healthcare costs. Despite the development of consensus-based best practices to prevent surgical site infection, there is still considerable variation in minimizing modifiable risk factors. The payment approach known as “pay-for-performance” (P4P) has gained traction as a strategy for promoting quality improvement (QI) by rewarding clinicians who meet performance expectations with respect to health care quality. In 2016, a commercial insurer and the Columbia University Department of Orthopedic Surgery agreed to test if P4P could improve compliance to consensus-based best practices to prevent, including the use of preoperative chlorhexidine gluconate (CHG) wipes, standardized preoperative timing, dosing, and redosing of intravenous (IV) antibiotics, and the use of intraoperative intrawound vancomycin.
We reviewed the electronic health record and anesthetic chart for patients undergoing thoracolumbar spine instrumentation surgery from September 2015 to December 2016. to identify the specific orders and compliance with the protocol. Compliance was compared prior to the start of the P4P program in September-December 2015 (baseline) and at each calendar year quarter after it began in 2016 (Q1: January-March; Q2: April-June; Q3: July-September; Q4: October-December). Compliance to the entire bundle required a patient receiving preoperative CHG, all intravenous antibiotics at the appropriate time and dose, and intraoperative intrawound vancomycin.
537 spine surgeries were identified and performed by 9 surgeons during this time period. IV antibiotic compliance was 60% at baseline, 61% in Q1, 85% in Q2, 94% in Q3, and 92% in Q4. Preoperative CHG use was 65% at baseline, 95% in Q1, 100% in Q2, 100% in Q3, and 97% in Q4. Intrawound vancomycin compliance was 78% at baseline, 91% in Q1, 99% in Q2, 100% in Q3, and 100% in Q4. Total bundle compliance was 40% at baseline, 54% in Q1, 84% in Q2, 94% in Q3, and 92% in Q4 (see figure).
Simultaneously, the Center for Disease Control National Healthcare Safety Network (CDC-NHSN) showed that Columbia Orthopedics’ Standardized Infection Ratio (SIR) of observed to expected SSI fell from 0.821 to 0.536.
A novel P4P program dramatically increases compliance to modify SSI prevention processes. Quality improvement strategies may take at least 1 quarter before results improve due to the time lag that results from change management and communicating the diffusion of best practice. P4P is a quality improvement strategy that uses economic incentives to influence surgeon behavior change.