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The 30-Day Versus In-Hospital and 90-Day Mortality After Esophagectomy as Indicators for Quality of Care

Talsma, A. Koen MD*; Lingsma, Hester F. PhD; Steyerberg, Ewout W. PhD; Wijnhoven, Bas P. L. MD, PhD*; Van Lanschot, J. Jan B. MD, PhD*

doi: 10.1097/SLA.0000000000000482
Original Articles

Objective: To describe causes of death in the first year after esophagectomy and determine the time frame that should be used for measurement of quality of surgery. A case-mix adjustment model was developed for the comparison between hospitals.

Background: The time period in which postoperative mortality should be measured as a performance indicator is debated.

Methods: Cause of death was identified for patients in a tertiary referral hospital who died within 1 year after surgery and classified as surgery related or not surgery related. Sensitivity and specificity for detecting deaths related to surgery were calculated for different periods of follow-up. Case-mix adjustment models for 30-day mortality (30DM), in-hospital mortality, and 90-day mortality (90DM) were developed.

Results: In total, 1282 patients underwent esophagectomy. 30DM was 2.9%, the in-hospital mortality rate was 5.1% and 90DM was 7%. Beyond 30 days, a substantial number of deaths were related to the operation, especially due to anastomotic leakage. Postdischarge nononcological mortality was most frequently caused by sudden death. One in 5 patients died because of recurrent disease, being the most important threat in the first year after surgery. The 30DM had a sensitivity for detecting surgery-related deaths of 33% and a specificity of 100%. The 90DM had a sensitivity of 74% and a specificity of 96%.

Conclusions: A period of postoperative follow-up longer than 30 days needs to be considered when comparing surgical performance between institutes. In the case-mix adjustment model for 90DM, no other variables have to be taken into account compared to those involved in 30DM.

Supplemental Digital Content is Available in the Text.This study classifies causes of death in the first year after esophagectomy in 1282 patients. Because deaths related to surgery continue to occur after the traditional 30 days, longer periods of postoperative follow-up have to be considered as performance indicators.

Departments of *Surgery and

Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands.

Reprints: A. Koen Talsma, MD, Department of Surgery, Erasmus University Medical Center, Room H-828, PO Box 2040; 3000 CA Rotterdam, The Netherlands. E-mail:

Type of study: retrospective cohort study

Disclosure: The authors declare that there is no financial or personal relationship with people or organizations that could inappropriately bias their work. No grants or support has been given from any institute for this work.

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© 2014 by Lippincott Williams & Wilkins.