Mortality after Elective Colon Resection: The Search for Outcomes that Define Quality in Surgical Practice - 28/03/12

Doi : 10.1016/j.jamcollsurg.2011.12.018

Adrian T. Billeter, MD ^a, Hiram C. Polk, MD, FACS ^a,^⁎ , Samuel F. Hohmann, PhD ^b, Motaz Qadan, MD, PhD ^a,^d, Donald E. Fry, MD, FACS ^c, Jeffrey R. Jorden, MD, FACS ^a, Michael H. McCafferty, MD, FACS ^a, Susan Galandiuk, MD, FACS ^a
^a Price Institute of Surgical Research, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY
^b University HealthSystem Consortium, Chicago, IL
^c Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL
^d Department of Surgery, Stanford University School of Medicine, Stanford, CA

Correspondence address: Hiram C Polk Jr, MD, Department of Surgery, University of Louisville School of Medicine, Louisville KY 40292

Résumé

Background

Process measures constitute the focal point of surgical quality studies. High levels of compliance with such processes have not correlated with improved outcomes. Wide ranges of reported hospital death rates led us to hypothesize that survival after elective colon resection would be a legitimate outcomes measure for quality of surgical practice.

Study Design

We studied risk-adjusted hospital mortality rates of 85,260 patients in teaching hospitals as reported to the University HealthSystem Consortium (UHC) January 1, 2005 to March 31, 2011. Data were analyzed by institution and surgeon (deidentified). There were 34,504 patients from the HealthCare Utilization Project (HCUP, 2007-2008), who provided a comparison group for nonteaching hospitals. Surgeons with less than 1 year of reported data were excluded.

Results

Elective colon resection mortality rates were densely concentrated around 1.56% for teaching hospitals and at 1.08% for defined surgeons. HCUP data demonstrated a 1.38% nonteaching hospital mortality rate. Neither hospital nor surgeon volume were determinants of mortality, and lower volume entities displayed the widest mortality variations. Among 193 teaching hospitals, there were 6 outliers (4.1%), defined as >2 standard deviations (SDs) above the mean. Similarly, 32 of 681 individual surgeons (4.7%) had a risk-adjusted hospital mortality rate >2SDs above the mean.

Conclusions

Elective colon resection is a safe procedure in both teaching hospitals and nonteaching hospitals, with an impressively homogenous mean mortality rate of 1.56% in teaching hospitals, and 1.38% in nonteaching hospitals. We reject our original hypothesis because the data do not sufficiently discriminate to permit the use of death after elective colon resection as a differentiating quality measure; however, the data do identify individual poor performers. Poor performing institutions/surgeons should seek extramural guidance to improve their outcomes or discontinue performing such operations.

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Abbreviations and Acronyms : HCUP, SCIP, SSI, UHC

Plan

Methods

Results

Hospital mortality

Mortality rates according to surgeon

Method of access mortality

	Disclosure Information: Dr Samuel F Hohmann is a long-term full-time employee of the University HealthSystem Consortium (UHC), Chicago, designated as Principal Consultant Comparative Data & Informatics Research. Dr Donald E Fry is a vice president of Michael Pine & Associates, consultant group in Chicago. All other authors have nothing to disclose.
	This work was supported in part by the Physician's Foundation for Health Systems Excellence and the John W and Barbara Thruston Atwood Price Trust Fund.