Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers

Kyle W Blackburn; Florence E Turrentine; Bruce D Schirmer; Peter T Hallowell; Natalia S Kubicki; Yinin Hu; Mark D Kligman

doi:10.1016/j.soard.2023.02.011

Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers

Surg Obes Relat Dis. 2023 Sep;19(9):1049-1057. doi: 10.1016/j.soard.2023.02.011. Epub 2023 Feb 15.

Authors

Kyle W Blackburn¹, Florence E Turrentine², Bruce D Schirmer², Peter T Hallowell², Natalia S Kubicki¹, Yinin Hu¹, Mark D Kligman³

Affiliations

¹ Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
² Division of General Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
³ Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address: mkligman@som.umaryland.edu.

PMID: 36931965
DOI: 10.1016/j.soard.2023.02.011

Abstract

Background: Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention.

Objectives: The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons.

Setting: Two mid-Atlantic quaternary care academic centers.

Methods: Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05).

Results: We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period.

Conclusions: RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

Keywords: Quality assurance; Quality control; Risk-adjusted cumulative sum.

Publication types

Multicenter Study

MeSH terms

Academic Medical Centers
Adult
Female
Gastric Bypass* / adverse effects
Gastric Bypass* / methods
Hospitals, High-Volume
Humans
Laparoscopy*
Male
Mid-Atlantic Region / epidemiology
Middle Aged
Patient Readmission / statistics & numerical data
Postoperative Complications / epidemiology
Quality Assurance, Health Care* / methods
Reoperation / statistics & numerical data
Retrospective Studies
Risk Adjustment
Surgeons*
Treatment Outcome
Work Performance*