Shih Terry, Cole Adam I, Al-Attar Paul M, Chakrabarti Apurba, Fardous Hussein A, Helvie Peter F, Kemp Michael T, Lee Chris, Shtull-Leber Eytan, Campbell Darrell A, Englesbe Michael J
*Department of Surgery, Academic Surgeon Development Program †Michigan Surgery Quality Collaborative, University of Michigan, Ann Arbor, MI.
Ann Surg. 2015 May;261(5):920-5. doi: 10.1097/SLA.0000000000001032.
We sought to determine the reliability of surgeon-specific postoperative complication rates after colectomy.
Conventional measures of surgeon-specific performance fail to acknowledge variation attributed to statistical noise, risking unreliable assessment of quality.
We examined all patients who underwent segmental colectomy with anastomosis from 2008 through 2010 participating in the Michigan Surgical Quality Collaborative Colectomy Project. Surgeon-specific complication rates were risk-adjusted according to patient characteristics with multiple logistic regression. Hierarchical modeling techniques were used to determine the reliability of surgeon-specific risk-adjusted complication rates. We then adjusted these rates for reliability. To evaluate the extent to which surgeon-level variation was reduced, surgeons were placed into quartiles based on performance and complication rates were compared before and after reliability adjustment.
A total of 5033 patients (n = 345 surgeons) undergoing partial colectomy reported a risk-adjusted complication rate of 24.5%. Approximately 86% of the variability of complication rates across surgeons was explained by measurement noise, whereas the remaining 14% represented true signal. Risk-adjusted complication rates varied from 0% to 55.1% across quartiles before adjusting for reliability. Reliability adjustment greatly diminished this variation, generating a 1.2-fold difference (21.4%-25.6%). A caseload of 168 colectomies across 3 years was required to achieve a reliability of more than 0.7, which is considered a proficient level. Only 1 surgeon surpassed this volume threshold.
The vast majority of surgeons do not perform enough colectomies to generate a reliable surgeon-specific complication rate. Risk-adjusted complication rates should be viewed with caution when evaluating surgeons with low operative volume, as statistical noise is a large determinant in estimating their surgeon-specific complication rates.
我们试图确定结肠切除术后特定外科医生的术后并发症发生率的可靠性。
传统的特定外科医生手术表现评估方法未能认识到因统计噪声导致的差异，存在对质量评估不可靠的风险。
我们研究了2008年至2010年参与密歇根外科质量合作结肠切除术项目的所有接受节段性结肠切除并吻合术的患者。根据患者特征，采用多因素逻辑回归对特定外科医生的并发症发生率进行风险调整。使用分层建模技术确定特定外科医生风险调整后并发症发生率的可靠性。然后我们对这些发生率进行可靠性调整。为了评估外科医生水平差异降低的程度，根据表现将外科医生分为四分位数，并比较可靠性调整前后的并发症发生率。
共有5033例患者（n = 345名外科医生）接受了部分结肠切除术，风险调整后的并发症发生率为24.5%。外科医生之间并发症发生率的变异性约86%由测量噪声解释，而其余14%代表真实信号。在进行可靠性调整之前，四分位数之间的风险调整后并发症发生率从0%到55.1%不等。可靠性调整大大减少了这种差异，产生了1.2倍的差异（21.4% - 25.6%）。需要3年期间168例结肠切除术的病例量才能达到超过0.7的可靠性，这被认为是一个熟练水平。只有1名外科医生超过了这个病例量阈值。
绝大多数外科医生进行的结肠切除术数量不足以产生可靠的特定外科医生并发症发生率。在评估手术量低的外科医生时，应谨慎看待风险调整后的并发症发生率，因为统计噪声在估计他们的特定外科医生并发症发生率中是一个很大的决定因素。
