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CUSUM Analysis of Anastomotic Leak Rates Following Esophagectomy Provides a Tool to Identify Quality Problems and Evaluate Sources of Improved Outcomes
Patrick J. McLaren*, James P. Dolan, John G. Hunter
General Surgery, Oregon Health and Science University, Portland, OR
Background and Aims:
Used in industry to monitor quality, CUSUM is an analytic tool that has been applied in health care to examine clinical outcomes. CUSUM is a summative plot of an event that occurs over time. The slope that is generated can be used to easily visualize rates of occurrence and deviations from an accepted rate. CUSUM can be used to monitor anastomotic leak rates following esophagectomy. We aim to analyze the efficacy of cumulative summation (CUSUM) analysis in identifying and investigating deviations from accepted rates of anastomotic leaks following esophagectomy.
Methods:
A single institution prospectively maintained esophageal disease registry was used to construct CUSUM plots for cervical gastroesophageal leak rates following esophagectomy. All patients undergoing esophagectomy with cervical anastomosis from 1995-2015 were included for analysis. Time points that deviated from an accepted leak rate of 10% were investigated for interventions that could account for these observed differences.
Results:
A total of 368 patients were analyzed. Thirty-nine cervical anastomotic leaks were identified for an overall anastomotic leak rate of 10.9%. Deviation below 10% is evident between 2010 and 2011. This time frame marks the implementation of our multidisciplinary esophageal cancer care pathway. Prior to the introduction of the pathway anastomotic leak rate was 14.5%, but after 2010 the anastomotic leak rates were determined to be 5.4%. Following the creation of a single esophageal resection team in September 2012 the CUSUM curve demonstrates leak rates fell further to 3.0%. (Figure 1)
Conclusions:
CUSUM analysis offers an easily constructed visual tool to monitor institutional quality. CUSUM analysis can be used to monitor gastroesophageal anastomotic leak rates, investigate sources of rate fluctuations, and ultimately evaluate success of interventions. Investigations into complications can identify quality problems and can lead to implementation of improved process measures that may lead to improved future outcomes.
 Figure 1: CUSUM plot of gastroesophageal anastomotic leaks following esophagectomy, 1995-2015. Early experience is represented in green (14.5%), after implementation of an esophageal cancer care pathway shown in red (5.4%), and after the creation of a single esophageal resection team in blue (3.0%). Gray reference lines represent projections for 10, 15, and 20% leak rates.
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