BACKGROUND Accurately estimating surgical risks is critical for shared decision making and informed consent. The Centers for Medicare and Medicaid Services may soon put forth a measure requiring surgeons to provide patients with patient-specific, empirically-derived estimates of postoperative complications. Our objectives were (1) to develop a universal surgical risk estimation tool, (2) to compare performance of the universal vs. prior procedure-specific Surgical Risk Calculators, and (3) to allow surgeons to empirically adjust the estimates of risk. STUDY DESIGN Using standardized clinical data from 393 ACS NSQIP hospitals, a web-based tool was developed to allow surgeons to easily enter 21 preoperative factors (demographics, comorbidities, procedure). Regression models were developed to predict 8 outcomes based on the preoperative risk factors. The universal model was compared to procedure-specific models. To incorporate surgeon input, a subjective Surgeon Adjustment Score, allowing risk estimates to vary within the estimate's confidence interval, was introduced and tested with 80 surgeons using 10 case scenarios. RESULTS Based on 1,414,006 patients encompassing 1,557 unique CPT codes, a universal Surgical Risk Calculator model was developed which had excellent performance for mortality (c-statistic=0.944; Brier=0.011[ where scores approaching zero are better]), morbidity (c-statistic=0.816, Brier=0.069), and 6 additional complications (c-statistics>0.8). Predictions were similarly robust for the universal calculator vs. procedure-specific calculators (e.g., colorectal). Surgeons demonstrated considerable agreement on the case scenario scoring (80-100% agreement), suggesting reliable score assignment between surgeons. CONCLUSIONS The ACS NSQIP Surgical Risk Calculator is a decision-support tool based on reliable multi-institutional clinical data which can be used to estimate the risks of most operations. The ACS NSQIP Surgical Risk Calculator will allow clinicians and patients to make decisions using empirically derived, patient-specific postoperative risks.

Readmissions after surgery were associated with new postdischarge complications related to the procedure and not exacerbation of prior index hospitalization complications, suggesting that readmissions after surgery are a measure of postdischarge complications. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission.

ACS-NSQIP indicates that surgical outcomes improve across all participating hospitals in the private sector. Improvement is reflected for both poor- and well-performing facilities. NSQIP hospitals appear to be avoiding substantial numbers of complications- improving care, and reducing costs. Changes in risk over time merit further study.

As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

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While overall morbidity and mortality for HPB surgery are low, peri-operative outcomes are heterogeneous and depend on diagnosis, procedure type, and key clinical factors. By combining these factors, an ACS-NSQIP "HPB Risk Calculator" may be developed in the future to help better risk-stratify patients being considered for complex HPB surgery.

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