Surgical Skill and Complication Rates after Bariatric Surgery

BackgroundClinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes. MethodsWe conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. We then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients. ResultsMean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, as compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%, P<0.001) and higher mortality (0.26% vs. 0.05%, P=0.01). The lowest quartile of skill was also associated with longer operations (137 minutes vs. 98 minutes, P<0.001) and higher rates of reoperation (3.4% vs. 1.6%, P=0.01) and readmission (6.3% vs. 2.7%) (P<0.001). ConclusionsThe technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon's proficiency. In this preliminary study, videos of gastric bypass operations submitted by 20 bariatric surgeons were rated by peer surgeons. Surgical-skill ratings were highly correlated with complication rates (14.5% for surgeons in the bottom quartile vs. 5.2% in the top quartile). A considerable body of research suggests that some surgeons have better results than others. Early studies of coronary-artery bypass surgery showed wide variation in risk-adjusted patient mortality across surgeons; studies of other procedures and other outcomes have shown similar variation among surgeons.(1)-(3) Efforts to reduce such variation have focused primarily on improving perioperative care. For example, the Surgical Care Improvement Project and related pay-for-performance programs have provided financial incentives to increase surgeons' compliance with evidence-based practices related to prophylaxis against surgical-site infection and venous thromboembolism. As of this writing, however, there is little evidence that such initiatives have improved ...