title: Prioritizing perioperative quality improvement in orthopaedic surgery.
abstract: BACKGROUND
  Surgical quality improvement has received increasing attention in recent years, but it is not clear where orthopaedic surgeons should focus their efforts for the greatest impact on perioperative safety and quality. We sought to guide these efforts by prioritizing orthopaedic procedures according to those that generate the greatest number of adverse events.
  
  
  METHODS
  We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify all patients who had undergone an orthopaedic surgical procedure between 2005 and 2007 (n = 7970). Patients were assigned to forty-four unique procedure groups on the basis of the Current Procedural Terminology (CPT) codes. We first assessed the relative contribution of each procedure group to the overall number of adverse events in the first thirty postoperative days, and we followed that with a description of their relative contribution to an excess length of stay in the hospital.
  
  
  RESULTS
  Ten procedures accounted for 70% of the adverse events and 65% of the excess hospital days. Hip fracture repair accounted for the greatest share of adverse events, followed by total knee arthroplasty, total hip arthroplasty, revision total hip arthroplasty, knee arthroscopy, laminectomy, lumbar/thoracic arthrodesis, and femoral fracture repair. No other procedure group accounted for >2% of the adverse events.
  
  
  CONCLUSIONS
  Only a few procedures account for the vast majority of adverse events in the first thirty days following orthopaedic surgery. Concentrating quality-improvement efforts on these procedures may be an effective way for surgeons and other stakeholders to improve perioperative care and reduce costs in orthopaedic surgery.
  
  
  METHODS
  Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive, 2912 Taubman Center, Ann Arbor, MI 48109, USA. petschil@umich.edu
authors.forename: Peter L
authors.initials: PL
authors.lastname: Schilling
authors.forename: Brian R
authors.initials: BR
authors.lastname: Hallstrom
authors.forename: John D
authors.initials: JD
authors.lastname: Birkmeyer
authors.forename: James E
authors.initials: JE
authors.lastname: Carpenter
mesh_terms: D039702:Current Procedural Terminology; D016208:Databases, Factual; D006292:Health Priorities; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D019637:Orthopedic Procedures / Q000009:adverse effects* / Q000592:standards; D011183:Postoperative Complications / Q000453:epidemiology; D011785:Quality Assurance, Health Care; D014481:United States / Q000453:epidemiology