Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation. Issue 2 (August 2016)

• Record Type: Journal Article
• Authors: McMillan, Matthew T.; Soi, Sameer; Asbun, Horacio J.; Ball, Chad G.; Bassi, Claudio; Beane, Joal D.; Behrman, Stephen W.; Berger, Adam C.; Bloomston, Mark; Callery, Mark P.; Christein, John D.; Dixon, Elijah; Drebin, Jeffrey A.; Castillo, Carlos Fernandez-del; Fisher, William E.; Fong, Zhi Ven; House, Michael G.; Hughes, Steven J.; Kent, Tara S.; Kunstman, John W.; Malleo, Giuseppe; Miller, Benjamin C.; Salem, Ronald R.; Soares, Kevin; Valero, Vicente; Wolfgang, Christopher L.; Vollmer, Charles M.
• Is Part Of: Annals of surgery. Volume 264:Issue 2(2016:Aug.)
• Page Start: 344
• Page End: 352
• Publication Date: 2016-08
• Subjects: Fistula Risk Score -- pancreatic fistula -- pancreatoduodenectomy -- performance assessment -- risk adjustment; Surgery -- Periodicals; 617.005
• DOI: 10.1097/SLA.0000000000001537
• Languages: English
• ISSNs: 0003-4932

Abstract

Abstract : Supplemental Digital Content is available in the text Abstract : Objective: To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator. Background: Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk. Methods: This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance. Results: There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment. Conclusions: This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.