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Thirty-Day Mortality Underestimates Incidence of Death After Colorectal Surgery for Cancer
Mohamed A. Adam*, Zhifei Sun, jina kim, John Migaly, Christopher R. Mantyh
Department of Surgery, Duke University, Durham, NC

Thirty-day mortality after surgery is a critical quality metric of surgical care in the United States on which hospitals and surgeons are benchmarked. However, certain cancer surgical procedures are complex, with increased risk of complications after 30 days. Our aims were to compare incidence of 30-day vs. 90-day mortality after colorectal cancer surgery, and examine whether hospital performance ranking changes based on 30-day vs. 90-day mortality.
Adult patients undergoing major surgery for non-metastatic colorectal cancers were included from the National Cancer Data Base (2004-2012). Mortality rates were compared within 30 vs. 90 days from surgery. Risk-adjusted hierarchical logistic regression models were employed to evaluate hospital performance based on 30-day and 90-day mortality. Hospitals were ranked into top (10%), middle (80%), and lowest (10%) performance groups based on each metric.
Among 186,763 patients included, 106,333 (57%) had colon cancer, 52,899 (28%) rectal cancer, and 27,531 (15%) rectosigmoid cancer. Composite 90-day mortality was nearly double 30-day mortality (4.3% vs. 2.5%, p<0.01); 90-day mortality was similarly higher across all cancer sites (Figure). With adjustment, older patient age, male gender, lower income, lack of insurance, comorbidities, advanced tumor stage, and treatment at non-academic centers were associated with mortality within 31-90 days. Based on risk-adjusted 30-day mortality, 116 (10%) hospitals ranked in the top performance group, 953 (80%) in the middle performance group, and 116 (10%) hospitals in lowest performance group. When considering risk-adjusted 90-day mortality, 180 (15%) hospitals changed performance ranking; among this group, 41% of hospitals in the top 30-day mortality performance group changed ranking to the middle performance group based on 90-day mortality. 37% of hospitals in the lowest 30-day mortality group changed ranking to the middle 90-day mortality performance group. 5% of hospitals in the middle 30-day performance group changed their ranking to the top 90-day performance group, with additional 5% changed ranking to the lowest 90-day performance group;
A significant number of deaths after colorectal cancer surgery appear to occur beyond 30 days. Evaluation of hospital performance based on 30-day mortality is associated with misclassification of hospital ranking for 15% of hospitals. Evaluation of 90-day mortality may be a better quality metric in colorectal cancer surgery.

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