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The Importance of Assessing Both Inpatient and Outpatient Surgical Quality

Raval, Mehul V. MD, MS*,†; Hamilton, Barton H. PhD; Ingraham, Angela M. MD, MS*,§; Ko, Clifford Y. MD, MS, MSHS*,¶; Hall, Bruce L. MD, PhD, MBA

doi: 10.1097/SLA.0b013e318208fd50
Original Article
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Objective: We aimed to determine whether hospital-level surgical performance was similar across outpatient and inpatient settings.

Background: The majority of surgical procedures in the United States are performed in an outpatient setting but most quality improvement focuses on inpatient care.

Methods: Using data from the 2006 to 2008 American College of Surgeons- National Surgical Quality Improvement Program, risk-adjusted hospital observed to expected ratios for morbidity and mortality were compared for inpatient and outpatient cases. In addition, hospital outpatient performance in each year was compared with performances in subsequent years.

Results: Hospitals demonstrated variation in outcomes for outpatient morbidity with both good and poor outliers in each year. Outpatient mortality was so rare as to not support robust modeling. There was a lack of congruence between hospital performance for outpatient morbidity and either inpatient morbidity or inpatient mortality in each year, indicating that inpatient performance is not interchangeable with outpatient performance. Outpatient morbidity performance correlation between years was only moderate (correlations 0.449–0.534, all P < 0.001) indicating that although outcomes from 1 year mildly predict subsequent years, substitution of data would likely lead to missed opportunities for improvement.

Conclusions: Assessments of risk-adjusted hospital-level outpatient morbidity performance demonstrate (1) variability across American College of Surgeons- National Surgical Quality Improvement Program sites; (2) a lack of congruence between outpatient morbidity performance and either inpatient morbidity or mortality performance; (3) year-to-year variation of outpatient morbidity performance at individual institutions. Continuing evaluation of both outpatient and inpatient outcomes is supported. Given the substantial volume of outpatient care delivered, outpatient assessments are likely to be an important component of ongoing quality improvement efforts.

Though most surgical procedures in the United States are performed in an outpatient setting, most quality improvement focuses on inpatient care. Our study demonstrates risk-adjusted hospital-level outpatient morbidity variability, a lack of congruence between outpatient morbidity performance and inpatient performance, and year-to-year variation of performance at individual institutions.

From the *Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; †Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; ‡Olin Business School, Washington University in St. Louis, MO; §Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, ¶Department of Surgery, University of California Los Angeles David Geffen School of Medicine and the VA Greater Los Angeles Healthcare System, Los Angeles, CA; and ‖Department of Surgery, John Cochran Veterans Affairs Medical Center, Center for Health Policy and the Olin Business School, and Department of Surgery, School of Medicine, Washington University, St. Louis, MO.

M.V.R is supported by the John Gray Research Fellowship and the Daniel F. and Ada L. Rice Foundation. B.L.H was supported by the Center for Health Policy, under the direction of Dr. William Peck, Washington University in St. Louis, St. Louis, MO.

M.V.R and A.I.M participate in the American College of Surgeons Clinical Scholars in Residence Program. B.L.H also works on behalf of the American College of Surgeons National Surgical Quality Improvement Program for the American College of Surgeons No competing interests are declared by any author.

The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. This study does not represent the views or plans of the American College of Surgeons or the American College of Surgeons National Surgical Quality Improvement Program.

Reprints: Mehul V. Raval, MD, American College of Surgeons, 633 N. St. Clair, 22nd Floor, Chicago, IL 60611. E-mail: mraval@facs.org

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