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Validity and Feasibility of the American College of Surgeons Colectomy Composite Outcome Quality Measure

Merkow, Ryan P. MD, MS*,†,‡; Hall, Bruce L. MD, PhD, MBA*,§; Cohen, Mark E. PhD*; Wang, Xue PhD*; Adams, John L. PhD; Chow, Warren B. MD, MS*,‖; Lawson, Elise H. MD, MSHS; Bilimoria, Karl Y. MD, MS*,†; Richards, Karen BS*; Ko, Clifford Y. MD, MS, MSHS*,‖

doi: 10.1097/SLA.0b013e318273bf17
Original Articles

Objective: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure.

Background: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target.

Methods: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds.

Results: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%–26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008.

Conclusions: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

Performance measurement in surgery is required for quality improvement. The American College of Surgeons therefore developed a colectomy composite outcome measure for mortality or any serious morbidity. This measure is feasible, valid, has substantial clinical importance, and is projected to have acceptable reliability for 84% of colon resections performed in the United States.

*Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL

Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL

Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO

§Department of Surgery, Washington University in St Louis and Barnes Jewish Hospital; Center for Health Policy and the Olin Business School at Washington University in St Louis; Department of Surgery, John Cochran Veterans Affairs Medical Center, St Louis, MO

RAND Corporation, Santa Monica, CA

Department of Surgery, University of California, Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, CA.

Disclosure: RPM and WBC are supported by the American College of Surgeons Clinical Scholars in Residence Program, Chicago, IL. BLH, JLA, and KYB are consultants to the ACS NSQIP. The authors declare no conflicts of interest.

Reprints: Ryan P. Merkow, MD, MS, American College of Surgeons, 633 N. St. Clair St., 22nd Floor, Chicago, IL 60611. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.