title: Relationship of processes and structures of care in general surgery to postoperative outcomes: a hierarchical analysis.
abstract: BACKGROUND
  The majority of studies relating processes and structures of surgical care to outcomes focus on mortality alone, even though morbidity outcomes are frequent, costly, and can have an adverse effect on a patient's short- and longterm survival and quality of life. The purpose of this study was to identify the important processes and structures of surgical care that relate to 30-day, risk-adjusted postoperative morbidity in general surgery.
  
  
  METHODS
  Department of Veterans Affairs general surgery patients operated on in the period October 1, 2003 to September 30, 2004 at medical centers that participated in the Patient Safety in Surgery (PSS) Study and responded to a process and structure of care survey were included in this study. The patient's risk information was combined with key process and structure variables in a hierarchical maximum likelihood analysis to predict 30-day postoperative morbidity.
  
  
  RESULTS
  A number of hospital-level processes and structures of care were identified that predicted 30-day postoperative morbidity. The dominant factor was university affiliation. Affiliated hospitals showed an increase in risk of morbidity even after adjustment for patient risk.
  
  
  CONCLUSIONS
  Risk-adjusted morbidity is higher in Veterans Affairs hospitals that are affiliated with university medical centers. These findings mandate additional study to identify the exact factors responsible for this increased morbidity.
authors.affiliation: National Surgical Quality Improvement Program, Office of Patient Care Services, Department of Veterans Affairs, Aurora, CO, USA.
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Schifftner
authors.forename: Gary K
authors.initials: GK
authors.lastname: Grunwald
authors.forename: William G
authors.initials: WG
authors.lastname: Henderson
authors.forename: Debbi
authors.initials: D
authors.lastname: Main
authors.forename: Shukri F
authors.initials: SF
authors.lastname: Khuri
mesh_terms: D003625:Data Collection / Q000379:methods; D005260:Female; D006785:Hospitals, University; D006787:Hospitals, Veterans; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D013514:Surgical Procedures, Operative / Q000592:standards*; D016896:Treatment Outcome; D014481:United States