Highlights
- •Risk-adjusted cumulative sum (RA-CUSUM) adjusts for clinical risk factors to identify performance outliers in real-time.
- •RA-CUSUM is applicable to quality improvement/root-cause analysis in bariatric surgery.
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
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Article info
Publication history
Published online: February 14, 2023
Accepted:
February 4,
2023
Received:
October 30,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc.
