Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University and Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
J Am Coll Surg. 2013 Oct;217(4):685-93. doi: 10.1016/j.jamcollsurg.2013.05.015. Epub 2013 Jul 4.
Concern exists that oncologic surgical complexity is not adequately captured by the primary procedure code alone. Our objectives were to characterize the association between secondary procedures and 30-day outcomes, evaluate the effect of surgical complexity on risk predictions, and assess the influence of surgical complexity on hospital-quality comparisons.
Patients who underwent colon, rectal, or pancreatic resection for cancer (2007-2011) were identified from the American College of Surgeons NSQIP. Complexity was assessed by creating categorical complexity variables using secondary procedure codes and using total work relative value units. Regression methods were used to evaluate surgical complexity and hospital-quality comparisons.
Patients had at least one secondary procedure documented in 48.0% of colon, 55.5% of rectal, and 63.1% of pancreatic cases. Surgical complexity variables were associated with worse outcomes across nearly all complications assessed. For example, serious morbidity was increased after an index colon resection with a synchronous liver resection (odds ratio = 1.39; 95% CI, 1.10-1.76) and a pancreatic resection with vascular reconstruction (odds ratio = 1.21; 95% CI, 1.01-1.45). Based on discrimination improvement indices and the likelihood ratio test, model-based predictions were enhanced with the addition of secondary surgical complexity variables, as well as total work relative value units, for nearly all procedures and outcomes assessed. Models that included total work relative value units had similar or marginally better discrimination compared with models with secondary procedure categories. Hospital performance did not change substantially after complexity adjustment.
Surgical complexity adjustment is feasible and improves risk estimation of 30-day postoperative outcomes for colon, rectal, and pancreatic resections for cancer. Oncology-specific risk-adjustment models should include complexity adjustment using secondary procedure codes.
人们担心仅通过主要手术代码无法充分捕捉肿瘤外科手术的复杂性。我们的目的是描述次要手术与 30 天结果之间的关联，评估手术复杂性对风险预测的影响，并评估手术复杂性对医院质量比较的影响。
从美国外科医师学会 NSQIP 中确定了 2007-2011 年间因癌症接受结肠、直肠或胰腺切除术的患者。使用次要手术代码和总工作相对价值单位创建分类复杂性变量来评估复杂性。使用回归方法评估手术复杂性和医院质量比较。
在将近所有评估的并发症中，约有 48.0%的结肠癌、55.5%的直肠癌和 63.1%的胰腺癌患者至少有一个次要手术记录。在几乎所有评估的手术中，手术复杂性变量与更差的结果相关。例如，与单纯结肠切除术相比，同步行肝切除术的指数结肠切除术（优势比=1.39；95%置信区间，1.10-1.76）和行血管重建术的胰腺切除术（优势比=1.21；95%置信区间，1.01-1.45）严重发病率增加。基于区分改善指数和似然比检验，模型预测通过添加次要手术复杂性变量以及总工作相对价值单位，几乎可以改善所有评估的手术和结果的预测。包含总工作相对价值单位的模型与包含次要手术类别的模型相比，具有相似或略有改善的区分能力。在复杂性调整后，医院绩效并未发生重大变化。
手术复杂性调整是可行的，可提高结肠癌、直肠癌和胰腺癌切除术 30 天术后结果的风险估计。肿瘤特异性风险调整模型应包括使用次要手术代码进行复杂性调整。
