The Better Colectomy Project: Association of best-practice adherence rates to outcomes in colorectal surgery
*Alexander F Arriaga, MD 1 & 2 , *Robert T Lancaster, MD, MPH2 & 3 , *William R Berry, MD, MPH, MPA2 , *Scott E Regenbogen, MD, MPH2 & 3 , *Stuart R Lipsitz, ScD1 , *Haytham M.A. Kaafarani, MD, MPH 2 & 6 , *Andrew W Elbardissi, MD, MPH1 & 2 , *Priya Desai, BA, MPH1 & 2, *Stephen J. Ferzoco, MD4 , *Ronald Bleday, MD3, *Elizabeth Breen, MD1 , *William V. Kastrinakis, MD5 , *Marc S. Rubin, MD5 , *Atul A Gawande, MD, MPH1 & 2
1 Brigham and Women's Hospital, Boston, MA; 2 Harvard School of Public Health, Boston, MA; 3 Faulkner Hospital, Boston, MA; 4Faulkner Hospital, Boston, MA; 5North Shore Medical Center, Salem, MA; 6Veterans Affairs Boston Healthcare System, Boston, MA.
OBJECTIVE(S): The average postoperative complication rate for colon and rectal resections exceeds 25%. We sought to identify directions to reduce these complications by evaluating adherence to evidence-based best-practices.
METHODS: We retrospectively reviewed medical records for all patients undergoing colorectal resections at one academic and two community hospitals, from February to August 2007, for adherence to 37 perioperative best-practices identified by a panel of colorectal and general surgeons (15 practices were established as “key processes” for prevention of complications). We then evaluated the association of best-practice adherence to complications in a random subgroup of patients with outcome data available through the American College of Surgeons National Surgical Quality Improvement Program.
RESULTS: Among 371 consecutive patients, adherence rates were under 50% for 11 practices (including two key processes: avoidance of unnecessary blood transfusions, timely removal of central venous catheters). Among 198 patients with available outcome data, 38 (19%) experienced complications, of which 31 (82%) involved postoperative infection. Adherence to “key processes” was significantly predictive of the occurrence of a complication (p=0.002; see table). The odds ratio for one or more complications as the number of processes missed increased by one was 1.59 (95% confidence interval 1.17-2.16).
CONCLUSIONS: Failures of adherence to best-practices in colorectal surgery is associated with increased occurrence of complications. This merits further research to determine whether improvement in compliance will reduce complication rates significantly.