Reoperation as a quality indicator in colorectal surgery - A population-based analysis

Objective: To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay. Summary Background: Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored. Methods: Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database. Independent variables: sociodemographics, tumor characteristics, comorbidity, and acuity. Primary outcome: postoperative procedural intervention. Analysis: Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures. Results: A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI]=2.5-3.6), obstruction (RR=1.6; 95% CI=1.4-1.8), and emergent admission (RR=1.3; 95% CI=1.1-1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR=2.4; 95% CI=2.1-2.9) and prolonged hospitalization (RR=2.2; 95% CI=2.1-2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality=2.9; 95% CI=2.3-3.7), wound complications (21.1%; RR mortality=0.7; 95% CI=0.4-1.3), and organ injury (18.7%; RR mortality=1.6; 95% CI=1.1-2.3). Conclusions: Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.