Risk Adjusted Colon Surgery Outcome Measure

The outcome of interest is 30-day, hospital-specific risk-adjusted (all cause) mortality, unplanned reoperation, or any of the following morbidities as defined by American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP): cardiac arrest requiring CPR, myocardial Infarction, sepsis, septic shock, deep incisional surgical site infection (SSI), organ space SSI, wound disruption, unplanned reintubation without prior ventilator dependence, pneumonia without pre-operative pneumonia, progressive renal insufficiency or acute renal failure without pre-operative renal failure or dialysis, or urinary tract infection (UTI). All outcomes are definitively resolved within 30 days of any ACS NSQIP listed (CPT) surgical procedure. All variables (fields) are explicitly defined in the tradition of the ACS NSQIP and definitions are also submitted in these materials. The original endorsed measure included venous thromboembolism (VTE) as eligible morbidity events, including deep venous thrombosis requiring therapy and pulmonary embolism.

The current set of mortality and major complications for this measure was chosen based on prior work revealing that these complications are related to other important criteria such as large contributions to excess length of stay, large complication burdens, or correlations with mortality. (Merkow et al. 2013) In addition, the desire to limit the outcomes to significant events (ie- some degree of severity according to certain criteria) is the reason that superficial wound infection is excluded from the measure. The current submission removes VTE from the measure as recent publications have demonstrated it is highly subject to surveillance bias. A recent study of 2,838 hospitals found that increased VTE prophylaxis adherence was associated with worse risk-adjusted VTE event rates. (Bilimoria 2013 JAMA) Paradoxically hospitals with higher quality, identified by number of accreditations and quality initiatives, had worse VTE rates. The explanation for this paradoxical relationship is suggested by the association of higher rates of VTE imaging studies among these hospitals with higher rates of VTE detection. (Bilimoria, Chung et al. 2013, Ju, Chung et al. 2014, Chung, Ju et al. 2015)

Bilimoria, K. Y., J. Chung, M. H. Ju, E. R. Haut, D. J. Bentrem, C. Y. Ko and D. W. Baker (2013). "Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure." Jama 310(14): 1482-1489.
Chung, J. W., M. H. Ju, C. V. Kinnier, M. W. Sohn and K. Y. Bilimoria (2015). "Postoperative venous thromboembolism outcomes measure: analytic exploration of potential misclassification of hospital quality due to surveillance bias." Ann Surg 261(3): 443-444.
Ju, M. H., J. W. Chung, C. V. Kinnier, D. J. Bentrem, D. M. Mahvi, C. Y. Ko and K. Y. Bilimoria (2014). "Association between hospital imaging use and venous thromboembolism events rates based on clinical data." Ann Surg 260(3): 558-564; discussion 564-556.
Merkow RP, Hall BL, Cohen ME, et al. Validity and feasibility of the american college of surgeons colectomy composite outcome quality measure. Ann Surg. 2013;257(3):483-489.