Background Surgical quality programs, such as the American College of Surgeons NSQIP, provide reports based on specialty or procedure, with patients aggregated together. It is unknown whether hospital performance differs by patient subgroup (eg cancer vs noncancer patients), masking opportunities for improvement. Our objectives were to determine whether performance differs within a given hospital for 6 contrasting patient subgroups and to identify the percentage of hospitals with greater than chance differences in performance. Study Design Using the American College of Surgeons NSQIP data, adults undergoing lung resection, esophagectomy, hepatectomy, pancreatectomy, colectomy, and proctectomy (2005 through 2012) were divided into 6 contrasting subgroups (elderly vs nonelderly, white vs nonwhite, obese vs nonobese, renal insufficiency vs normal renal function, cancer vs noncancer, emergency vs nonemergency). The main end point was serious morbidity or mortality. Observed to expected ratios were constructed using hierarchical models and compared using paired t-tests (eg observed to expected for cancer cases compared with noncancer). Variation in performance differences was assessed using a randomization test and z-tests for proportions. Results From 433 hospitals, 221,518 patients were included. Overall quality differed for elderly vs nonelderly, renal insufficiency vs normal renal function patients, cancer vs noncancer, and emergency vs nonemergency (p < 0.05). Variation in within-hospital performance differences exceeded chance expectations for renal insufficiency vs normal renal function in 31.1% of hospitals, cancer vs noncancer in 40.8%, and emergency vs nonemergency patients in 55.4% (p < 0.001). Conclusions Hospital performance within a given hospital varies by patient subgroup. Quality programs can consider separate reports for these subgroups to identify opportunities for quality improvement.
Bibliographical noteFunding Information:
Support: This work was supported in part by the Agency for Healthcare Research and Quality (R21 HS21857-01; Principal Investigator: Dr Bilimoria) and American Cancer Society (280521; Principal Investigator: Dr Bilimoria). Dr Berian's fellowship position at the American College of Surgeons as a Clinical Scholar in Residence is supported by the American College of Surgeons Clinical Scholars in Residence Program, University of Chicago Medical Center, Northwestern University, and a grant from the John A Hartford Foundation. Dr Paruch's American College of Surgeons Clinical Scholars in Residence fellowship was supported by the American College of Surgeons, the University of Chicago, Northwestern University, and an unrestricted educational grant from Genentech, which had no input on the selection of the recipient, research topic, research direction, or the content of any resulting report, presentation, or publication.
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