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Surgeon Characteristics Supersede Hospital Characteristics in Mortality after Urgent Colectomy
Richard S. Hoehn*, Dennis J. Hanseman, Alex Chang, Meghan C. Daly, Audrey Ertel, Daniel E. Abbott, Shimul Shah, Ian M. Paquette
Surgery, University of Cincinnati, Cincinnati, OH

OBJECTIVES: Urgent colectomy is a common procedure with a high mortality rate performed by a variety of surgeons and hospitals. We investigated whether surgeon or hospital characteristics more strongly predicted mortality after urgent colectomy.
METHODS: The University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009-2013 (n=18,213). Observed-to-expected (O/E) mortality ratios were created and surgeons and hospitals were grouped into quartiles accordingly. For hospital analysis, data were linked to the American Hospital Association (AHA) Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality.
RESULTS: The overall mortality rate after urgent colectomy was 9.03%. Surgeons with the highest O/E mortality ratios tended to treat more patients who were black (Q4 vs Q1: 20% vs 15%), on Medicaid (17% vs 13%), and with extreme severity-of-illness (20% vs 12%; all p<0.001). These surgeons also performed more open cases (Q4 vs Q1: 87% vs 82%) and less total colectomies (9 vs 12%; all p<0.01). Similar associations were seen with hospital O/E ratios. Linkage with AHA data revealed that hospital characteristics did not differ significantly across O/E quartiles. Specifically, there were not significant correlations between hospital mortality rates and bed numbers, staffing (physicians, residents, nurses, technicians) or financial data (expenses, payroll, capital expenditures). On multivariate analysis (Table 1), age, male gender, Medicare insurance, and severity-of-illness were associated with postoperative mortality. Surgeon volume was inversely correlated with mortality while surgeons with a higher proportion of urgent cases (based on overall colectomy case load) had higher mortality. Hospital volume and case-mix were not statistically significant.
CONCLUSION: Mortality is common after urgent colectomy and correlates most strongly with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume may ignore other more important predictors of patient outcomes.

Table 1. Multivariate analysis of predictors of mortality after urgent colectomy.

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