Original Scientific Articles

Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy

Bamdad, Michaela C MD, MHS; Brown, Craig S MD, MS; Kamdar, Neil MA; Weng, Wenjing MS; Englesbe, Michael J MD, FACS; Lussiez, Alisha MD

Author Information

From the Department of Surgery, University of Michigan, Ann Arbor, MI.

Disclosure Information: The Michigan Surgical Quality Collaborative is funded as part of the Blue Cross Blue Shield of Michigan Value Partnership program.

Disclosures outside the scope of this work: Dr Englesbe receives salary support from Blue Cross Blue Shield of Michigan. Dr Kamdar is supported by Lucent Surgical and the University of New Mexico.

Support: Dr Lussiez is supported by National Cancer Institute Grant T32CA009672. Dr Englesbe receives funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse (R01DA042859).

Disclaimer: The content of this study is solely the responsibility of the authors and does not necessarily reflect the official views of Blue Cross Blue Shield of Michigan. No funder or sponsor had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Presented virtually at the AcademyHealth 2020 Annual Research Meeting, August 2020.

Supplemental digital content for this article is available at https://links.lww.com/XCS/A49.

Received August 25, 2021; Revised November 11, 2021; Accepted November 11, 2021.

Correspondence address: Alisha Lussiez, MD, Department of Surgery Education Office, 2110 Taubman Center, SPC 5346, 1500 East Medical Center Drive, Ann Arbor, MI 48109. email: [email protected]

Journal of the American College of Surgeons 234(3):p 300-309, March 2022. | DOI: 10.1097/XCS.0000000000000063

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BACKGROUND

Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy.

STUDY DESIGN

We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications.

RESULTS

A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7–3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2–12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5–85.6%) or 89.4% (CI 73.7–96.2%) risk of complication.

CONCLUSIONS

This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.