title: Importance of perioperative processes of care for length of hospital stay after laparoscopic surgery.
abstract: OBJECTIVE
  The technologic imperative has prompted the adoption of complex laparoscopic techniques by physicians with various degrees of skill. We sought to measure the impact of both case mix and physician practice (perioperative process/risk factors) on length of stay (LOS)-a common benchmark- after laparoscopic surgery.
  
  
  METHODS
  We identified 911 patients undergoing laparoscopic retroperitoneal surgery between 1996 and 2004, who comprise our study population. Patients remaining in the hospital >5 days-the 90th percentile for the sample-were classified as having a prolonged LOS. Adjusted models were developed to determine the independent association of case mix and process measures with a prolonged LOS. The likelihood ratio test was used to discern the improvement of fit of the process model compared with the case-mix model.
  
  
  RESULTS
  Among factors related to case mix and structure of care, increasing age (odds ratio [OR] 1.1; 95% CI 1.0, 1.2), less surgeon experience (OR 6.1; 95% CI 2.1, 17.2), male gender (OR 2.1; 95% CI 1.2, 4.0), and American Society of Anesthesiologists score of 3 or 4 (OR 7.2; 95% CI 2.2, 23.3) were independently associated with a prolonged LOS. The need for a transfusion (OR 9.4; 95% CI 33.9, 23.2), the development of a postoperative complication (OR 4.6; 95% CI 2.2, 9.5), and longer operative time (OR 1.5; 95% CI 1.3, 1.8) explained additional variation in prolonged LOS outcomes when considering perioperative process/risk factors in the model. Perioperative factors significantly improved the fit of the model (chi (2) statistic 101.8; p < 0.0001).
  
  
  CONCLUSIONS
  Significant variation in outcomes is explained by factors describing aspects of surgical expertise. Variability in the surgical skill set is likely greatest during the laparoscopic learning curve, which raises a quality-of-care concern during the initial implementation of the technique. Policies attempting to smooth the laparoscopic learning curve, such as mentoring and skill measurement prior to credentialing, could improve the quality of care.
authors.affiliation: Department of Urology, The University of Michigan, Ann Arbor, Michigan, USA. bhollen@umich.edu
authors.forename: Brent K
authors.initials: BK
authors.lastname: Hollenbeck
authors.forename: William W
authors.initials: WW
authors.lastname: Roberts
authors.forename: J Stuart
authors.initials: JS
authors.lastname: Wolf
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care; D011183:Postoperative Complications; D012307:Risk Factors; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000379:methods