Surgeon-Level Variation in Postoperative Complications.

BACKGROUND: Variation in surgical outcomes is often attributed to patient comorbidities and the severity of underlying disease, but little is known about the extent of variation in outcomes by surgeon and the surgeon factors that are associated with quality.

METHODS: Using the Maryland Health Services Cost Review Commission database, we evaluated risk-adjusted postoperative events by surgeon. Operations studied were elective laparoscopic and open colectomy procedures for colon cancer performed over a 2-year period (July 2012-September 2014). Postoperative events were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators. Surgeons performing fewer than ten procedures during the study period were excluded. Logistic regression and post-estimation were used to calculate an observed-to-expected (O/E) ratio of postoperative complications for each surgeon, adjusting for patient and surgeon characteristics.

RESULTS: A total of 2525 patients underwent an elective colectomy during the study period by 276 surgeons at 44 hospitals. Postoperative complications varied more by surgeon (range 0 to 30.0 %) than by hospital (range 0 to 18.2 %). Surgeon-level use of laparoscopic surgery to perform colectomy ranged from 0 to 100 %. After risk adjustment with patient factors, surgeon experience, surgeon medical school, surgeon gender, and annual surgeon colectomy volume were not associated with postoperative complications. Surgeon use of laparoscopy was the strongest predictor of lower complications (vs fourth quartile of surgeons, first quartile OR = 0.47 (0.26-0.85); second quartile OR = 0.41 (0.22-0.73); and third quartile OR = 0.84 (0.52-1.36).

CONCLUSIONS: Quality metrics in health care have been measured at the hospital level, but a greater quality improvement potential exists at the surgeon level. Awareness of this variation could better inform patients undergoing elective surgery and their referring physicians.