title: System-based factors influencing intraoperative decision-making in rectal cancer by surgeons: an international assessment.
abstract: OBJECTIVE
  Sound surgical judgement is the goal of training and experience; however, system-based factors may also colour selection of options by a surgeon. We analysed potential organizational characteristics that might influence rectal cancer decision-making by an experienced surgeon.
  
  
  METHODS
  One hundred and seventy-three international centres treating rectal cancer were invited to participate in a survey assessment of key treatment options for patients undergoing curative rectal-cancer surgery. The key organizational characteristics were analysed using multivariate methods for association with intra-operative surgical decision-making.
  
  
  RESULTS
  The response rate was 71% (123 centres). Sphincter-saving surgery was more likely to be performed at university hospitals (OR=3.63, P=0.01) and by high-caseload surgeons (OR=2.77 P=0.05). A diverting stoma was performed more frequently in departments with clinical audits (OR=3.06, P=0.02), and a diverting stoma with coloanal anastomosis was more likely in European centres (OR=4.14, P=0.004). One-stage surgery was less likely where there was assessment by a multidisciplinary team (OR=0.24, P=0.02). Multivariate analysis showed that university hospital, clinical audit, European centre, multidisciplinary team and high caseload significantly impacted on surgical decision-making.
  
  
  CONCLUSIONS
  Treatment variance of rectal cancer surgeons appears to be significantly influenced by organizational characteristics and complex team-based decision-making. System-based factors may need to be considered as a source of outcome variation that may impact on quality metrics.
authors.affiliation: Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio 44106-5047, USA.
authors.forename: K M
authors.initials: KM
authors.lastname: Augestad
authors.forename: R-O
authors.initials: RO
authors.lastname: Lindsetmo
authors.forename: J J
authors.initials: JJ
authors.lastname: Stulberg
authors.forename: H
authors.initials: H
authors.lastname: Reynolds
authors.forename: B
authors.initials: B
authors.lastname: Champagne
authors.forename: A J
authors.initials: AJ
authors.lastname: Senagore
authors.forename: C P
authors.initials: CP
authors.lastname: Delaney
mesh_terms: D001315:Australia; D054869:Clinical Audit; D003430:Cross-Sectional Studies; D003657:Decision Making; D013505:Digestive System Surgical Procedures / Q000379:methods / Q000523:psychology*; D005060:Europe; D019538:Health Care Surveys; D006785:Hospitals, University; D006801:Humans; D007432:Intraoperative Period; D015999:Multivariate Analysis; D015279:Organizational Culture; D010348:Patient Care Team / Q000458:organization & administration; D010820:Physicians / Q000523:psychology*; D011365:Professional Practice Location; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D011795:Surveys and Questionnaires; D013598:Systems Theory; D014481:United States; D016526:Workload