Anastomotic leakage as an outcome measure for quality of colorectal cancer surgery

• Published in: BMJ quality & safety Vol. 22; no. 9; pp. 759 - 767
• Main Authors: Snijders, H S, Henneman, D, van Leersum, N L, ten Berge, M, Fiocco, M, Karsten, T M, Havenga, K, Wiggers, T, Dekker, J W, Tollenaar, R A E M, Wouters, M W J M
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd 01.09.2013; BMJ Group; BMJ Publishing Group LTD
• Subjects: Anastomosis, Surgical - standards; Anastomotic Leak - etiology; Anastomotic Leak - mortality; Audit and feedback; Audits; Biological and medical sciences; Cancer surgery; Colorectal cancer; Colorectal carcinoma; Colorectal Neoplasms - surgery; Colorectal surgery; Confidence Intervals; Datasets; Diagnosis-Related Groups; Female; Gastroenterology. Liver. Pancreas. Abdomen; Health administration; Hospitals; Humans; Logistic Models; Male; Medical Audit; Medical sciences; Miscellaneous; Mortality; Mortality (standardized mortality ratios); Odds Ratio; Ostomy; Outcome Assessment (Health Care); Prospective Studies; Public health. Hygiene; Public health. Hygiene-occupational medicine; Quality Indicators, Health Care; Quality measurement; Risk Factors; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; Studies; Surgery; Tumors; Colonic disease; Rectal disease; Prognosis; Quality; Colorectal cancer; Leak; Digestive diseases; Intestinal disease; Evolution; Malignant tumor; Cancer; Quality measurement; Mortality (standardized mortality ratios); Audit and feedback; Surgery
• ISSN: 2044-5415; 2044-5423
• DOI: 10.1136/bmjqs-2012-001644

Introduction When comparing mortality rates between hospitals to explore hospital performance, there is an important role for adjustment for differences in case-mix. Identifying outcome measures that are less influenced by differences in case-mix may be valuable. The main goal of this study was to explore whether hospital differences in anastomotic leakage (AL) and postoperative mortality are due to differences in case-mix or to differences in treatment factors. Methods Data of the Dutch Surgical Colorectal Audit were used. Case-mix factors and treatment-related factors were identified from the literature and their association with AL and mortality were analysed with logistic regression. Hospital differences in observed AL and mortality rates, and adjusted rates based on the logistic regression models were shown. The reduction in hospital variance after adjustment was analysed with Levene's test for equality of variances. Results 17 of 22 case-mix factors and 4 of 11 treatment factors related to AL derived from the literature were available in the database. Variation in observed AL rates between hospitals was large with a maximum rate of 17%. This variation could not be attributed to differences in case-mix but more to differences in treatment factors. Hospital variation in observed mortality rates was significantly reduced after adjustment for differences in case-mix. Conclusions Hospital variation in AL is relatively independent of differences in case-mix. In contrast to ‘postoperative mortality’ the observed AL rates of hospitals evaluated in our study were only slightly affected after adjustment for case-mix factors. Therefore, AL rates may be suitable as an outcome indicator for measurement of surgical quality of care.