Benchmarks in colorectal surgery: multinational study to define quality thresholds in high and low anterior resection

Abstract

Background Benchmark comparisons in surgery allow identification of gaps in the quality of care provided. The aim of this study was to determine quality thresholds for high (HAR) and low (LAR) anterior resections in colorectal cancer surgery by applying the concept of benchmarking. Methods This 5-year multinational retrospective study included patients who underwent anterior resection for cancer in 19 high-volume centres on five continents. Benchmarks were defined for 11 relevant postoperative variables at discharge, 3 months, and 6 months (for LAR). Benchmarks were calculated for two separate cohorts: patients without (ideal) and those with (non-ideal) outcome-relevant co-morbidities. Benchmark cut-offs were defined as the 75th percentile of each centre’s median value. Results A total of 3903 patients who underwent HAR and 3726 who had LAR for cancer were analysed. After 3 months’ follow-up, the mortality benchmark in HAR for ideal and non-ideal patients was 0.0 versus 3.0 per cent, and in LAR it was 0.0 versus 2.2 per cent. Benchmark results for anastomotic leakage were 5.0 versus 6.9 per cent for HAR, and 13.6 versus 11.8 per cent for LAR. The overall morbidity benchmark in HAR was a Comprehensive Complication Index (CCI®) score of 8.6 versus 14.7, and that for LAR was CCI® score 11.9 versus 18.3. Conclusion Regular comparison of individual-surgeon or -unit outcome data against benchmark thresholds may identify gaps in care quality that can improve patient outcome.

Benchmarking: a novel measuring tool for outcome comparisons in surgery

“… 2 summarized benchmarking in surgery as a quality-improvement tool to measure the best achievable results in a cohort with well-defined low-risk patients to establish meaningful reference values (benchmarks) for outcome comparisons among organizations or over time or to assess the enforcement of novel surgical techniques 18 . Benchmarking has been reported in esophagectomy, liver transplantation, hepatobiliary surgery, pancreatic surgery, and bariatric surgery 16 17 18 19 21 22 23 26 27 28 30 31 32 33 34 37 . Russolillo et al 24 adopted the definition that benchmark was the performance of the top 10% ranked providers adjusted by sample sizes of each provider according to the ‘Achievable Benchmark of Care’ (ABC) method 29 , 36 , 50 .…”

“…Outcome comparisons in surgery also include other clinically relevant outcome parameters such as readmission, length of stay, and comprehensive complication index (CCI) 12 13 14 . Currently, benchmarking targeting clinically relevant outcome measures for complex surgical procedures has become the focus in surgery 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 .…”

Classification of Adverse Events in Adult Surgery

“…18 The research group of Clavien et al introduced the notion of global outcome benchmarks, where procedure-specific outcome goals are set for a list of clinically relevant quality indicators (QIs), based on the 75th percentile of the outcomes obtained in international high-volume centers. 11,13,[19][20][21][22][23][24][25][26][27][28][29][30][31][32] Global outcome benchmarks have been so far established for minimally invasive esophagectomy, 25 liver surgery, 26 liver transplantation, 24,31 ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), 22 pancreatic surgery, 20,23 colorectal resections, 32 as well as for bariatric surgery 19,21 (►Table 1). Meanwhile, Kolfschoten et al developed a composite outcome measure representing the percentage of patients with textbook outcomes, meaning that all desired health outcomes are reached simultaneously.…”

Quality and Outcome Assessment for Surgery

“…While benchmarking originally comes from the fields of economy, it is now widely adopted in medicine 52,53 . Since 2016, such benchmark values have already been determined for >15 procedures by several groups in various field of general surgery 52–65 …”

“…52,53 Since 2016, such benchmark values have already been determined for > 15 procedures by several groups in various field of general surgery. [52][53][54][55][56][57][58][59][60][61][62][63][64][65] A possible routine use of the benchmark values is to select patients with outcome parameters outside of the benchmark values for discussion at the institutional multidisciplinary morbidity-mortality conferences. Poorer outcome than benchmark values may relate to deficiencies in care or just because the patient belongs to a higher risk group.…”