Background
Most risk adjustment approaches adjust for patient comorbidities and the primary procedure.
However, procedures done at the same time as the index case may increase operative
risk and merit inclusion in adjustment models for fair hospital comparisons. Our objectives
were to evaluate the impact of surgical complexity on postoperative outcomes and hospital
comparisons in gastric cancer surgery.
Methods
Patients who underwent gastric resection for cancer were identified from a large clinical
dataset. Procedure complexity was characterized using secondary procedure CPT codes
and work relative value units (RVUs). Regression models were developed to evaluate
the association between complexity variables and outcomes. The impact of complexity
adjustment on model performance and hospital comparisons was examined.
Results
Among 3,467 patients who underwent gastrectomy for adenocarcinoma, 2,171 operations
were distal and 1,296 total. A secondary procedure was reported for 33% of distal
gastrectomies and 59% of total gastrectomies. Six of 10 secondary procedures were
associated with adverse outcomes. For example, patients who underwent a synchronous
bowel resection had a higher risk of mortality (odds ratio [OR], 2.14; 95% CI, 1.07–4.29)
and reoperation (OR, 2.09; 95% CI, 1.26–3.47). Model performance was slightly better
for nearly all outcomes with complexity adjustment (mortality c-statistics: standard
model, 0.853; secondary procedure model, 0.858; RVU model, 0.855). Hospital ranking
did not change substantially after complexity adjustment.
Conclusion
Surgical complexity variables are associated with adverse outcomes in gastrectomy,
but complexity adjustment does not affect hospital rankings appreciably.
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Article info
Publication history
Published online: May 20, 2015
Accepted:
March 30,
2015
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
