title: Improving surgical outcomes through adoption of evidence-based process measures: intervention specific or associated with overall hospital quality?
abstract: BACKGROUND
  The Leapfrog Group aims to improve surgical outcomes through promoting hospital adoption of procedure-specific process measures, although it is unclear whether compliance reflects a hospital's overall quality. The purpose of this study was to evaluate whether implementation of Leapfrog's standard for routine beta-blockade was associated with reductions in mortality after open abdominal aortic aneurysm (AAA) repair alone versus other high-risk operations.
  
  
  METHODS
  Using a 2:1 matched case-control study design, hospitals that had not adopted the beta-blockade standard (n = 72) were compared with hospitals that had implemented this Leapfrog standard (n = 36). Leapfrog survey data were linked to patient outcomes in the California OSHPD database from 2000 to 2005. Random-effects Poisson regression models were used to evaluate in-hospital mortality over time for patients undergoing AAA repair versus esophagectomy, hepatectomy, pancreatectomy, colectomy, gastrectomy, and pulmonary lobectomy.
  
  
  RESULTS
  A total of 6,199 AAA repairs, 2,780 esophagectomies, 2,544 hepatectomies, 2,909 pancreatectomies, 57,795 colectomies, 6,267 gastrectomies, and 10,210 lobectomies were analyzed. AAA-associated mortality significantly declined in hospitals that adopted the beta-blocker standard (relative risk [RR]: 0.49; 95% confidence interval [CI]: 0.24-0.97; P < .05). Implementation of this Leapfrog standard had no effect on reducing adjusted mortality rates for other high-risk operations, including esophagectomy (RR: 0.70; 95% CI: 0.25-1.89), hepatectomy (RR: 1.16; 95% CI: 0.32-4.29), pancreatectomy (RR: 0.76; 95% CI: 0.28-2.02), colectomy (RR: 1.12; 95% CI: 0.86-1.44), gastrectomy (RR: 1.17; 95% CI: 0.57-2.43), and lobectomy (RR: 0.98; 95% CI: 0.46-2.08) (all P > .05).
  
  
  CONCLUSIONS
  Compliance with peri-operative beta-blockade resulted in a significant reduction in mortality after open AAA repair over time, but it had no crossover effect on mortality associated with other high-risk operations in the same hospital. These data suggest that improvements in outcomes resulting from the adoption of evidence-based process measures are procedure specific and do not necessarily reflect overall hospital quality.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Brooke
authors.forename: Robert A
authors.initials: RA
authors.lastname: Meguid
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Perler
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D002140:California; D016022:Case-Control Studies; D019317:Evidence-Based Medicine; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals / Q000592:standards*; D006801:Humans; D011785:Quality Assurance, Health Care / Q000592:standards; D018570:Risk Assessment; D012449:Safety; D013514:Surgical Procedures, Operative / Q000592:standards*; D016896:Treatment Outcome