CUSUM analysis of J-pouch surgery reflects no learning curve after board certification

• Published in: Canadian Journal of Surgery Vol. 51; no. 4; pp. 296 - 299
• Main Author: Colquhoun, Patrick H.D., PhD, MD
• Format: Journal Article
• Language: French; English
• Published: Canada CMA Impact Inc 01.08.2008; CMA Impact, Inc; Canadian Medical Association
• Subjects: Adolescent; Adult; Aged; Analysis; Care and treatment; Certification; Clinical Competence; Colonic Diseases - epidemiology; Colonic Diseases - surgery; Colonic Pouches - standards; Education, Medical, Continuing - standards; Educational Measurement - methods; Female; Humans; Learning curves; Licensing, certification and accreditation; Male; Medical practices; Middle Aged; Morbidity; Ontario - epidemiology; Original; Outcome Assessment (Health Care); Patient outcomes; Practice; Prospective Studies; Severity of Illness Index; Specialty Boards; Surgeons; Surgery; Survival Rate - trends; Ulcerative colitis; Ontario; Canada
• ISSN: 0008-428X; 1488-2310
• DOI: 10.1016/S0008-428X(08)50078-6

Objective To investigate changes in morbidity and mortality associated with ileal J-pouch surgery performed during the first 3 years of a single surgeon’s practice to determine the presence or absence of a learning curve after fellowship training. Methods From July 2002 to July 2005, an observational study of postoperative outcomes was undertaken, in which 30-day and inhospital morbidity and mortality were assessed. A total of 37 patients (17 women and 20 men) underwent the surgery; their average age was 32 (range 16–51) years. The operation was performed for ulcerative colitis n = 31), familial adenomatous polyposis n = 4) and indeterminate colitis n = 2); 32 were diverted and 5 were not. Predicted morbidity and mortality were 31.66% and 1.47%, respectively. Observed morbidity and mortality were 29.7% and 0%, respectively. I used a risk-adjusted cumulative sum (CUSUM) model to compare observed outcomes with predicted outcomes according to a validated scoring system and to analyze outcomes with adjusting for risk on a case-by-case basis. Results CUSUM analysis revealed a flat curve trending down over the duration. Conclusion CUSUM methodology permits documentation of quality control during the first 3 years of practice. The experience of a single board-certified colorectal surgeon reveals acceptable results in the first 3 years of practice, with no obvious learning curve. The results suggest that fellowship training and board certification conferred reasonable proficiency in J-pouch surgery before the onset of practice.