title: Establishing a quantitative benchmark for morbidity in pancreatoduodenectomy using ACS-NSQIP, the Accordion Severity Grading System, and the Postoperative Morbidity Index.
abstract: OBJECTIVE
  The study aim was to quantify the burden of complications of pancreatoduodenectomy (PD).
  
  
  BACKGROUND
  The Postoperative Morbidity Index (PMI) is a quantitative measure of the average burden of complications of a procedure. It is based on highly validated systems--ACS-NSQIP and the Modified Accordion Severity Grading System.
  
  
  METHODS
  Nine centers contributed ACS-NSQIP complication data for 1589 patients undergoing PD from 2005 to 2011. Each complication was assigned a severity weight ranging from 0.11 for the least severe complication to 1.00 for postoperative death, and PMI was derived. Contribution to total burden by each complication grade was used to generate a severity profile ("spectrogram") for PD. Associations with PMI were determined by regression analysis.
  
  
  RESULTS
  ACS-NSQIP complications occurred in 528 cases (33.2%). The non-risk-adjusted PMI was 0.115 (SD = 0.023) for all centers and 0.113 (SD = 0.005) for the 7 centers that contributed at least 100 cases. Grade 2 complications were predominant in frequency, and the most common complication was postoperative bleeding/transfusion. Frequency and burden of complications differed markedly. For instance, severe complications (grades 4/5/6) accounted for only about 20% of complications but for more than 40% of the burden of complications. Organ space infection had the highest burden of any complication. The average burden in cases in which a complication actually occurred was 0.346.
  
  
  CONCLUSIONS
  This study develops a quantitative non-risk-adjusted benchmark for postoperative morbidity of PD. The method quantifies the burden of types and grades of postoperative complications and should prove useful in identifying areas that require quality improvement.
authors.affiliation: *Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA †Department of Surgery, Washington University School of Medicine in St Louis, St Louis, MO ‡Olin Business School and the Center for Health Policy, Washington University in St Louis, St Louis, MO; Department of Surgery, BJC Healthcare, St Louis, MO §Department of Surgery, Columbia University School of Medicine, New York, NY ‖Department of Surgery, Indiana University School of Medicine, Indianapolis, IN ¶Department of Surgery, University of Tennessee Health Science Center, Memphis, TN **Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA ††Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL ‡‡Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD §§Department of Surgery, Temple University School of Medicine, Philadelphia, PA; and ¶¶Department of Surgery, University of Wisconsin School of Medicine, Madision, WI.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Vollmer
authors.forename: Russell S
authors.initials: RS
authors.lastname: Lewis
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Hall
authors.forename: John D
authors.initials: JD
authors.lastname: Allendorf
authors.forename: Joal D
authors.initials: JD
authors.lastname: Beane
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Behrman
authors.forename: Mark P
authors.initials: MP
authors.lastname: Callery
authors.forename: John D
authors.initials: JD
authors.lastname: Christein
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Drebin
authors.forename: Irene
authors.initials: I
authors.lastname: Epelboym
authors.forename: Jin
authors.initials: J
authors.lastname: He
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
authors.forename: Emily
authors.initials: E
authors.lastname: Winslow
authors.forename: Christopher
authors.initials: C
authors.lastname: Wolfgang
authors.forename: Steven M
authors.initials: SM
authors.lastname: Strasberg
mesh_terms: D000368:Aged; D019985:Benchmarking; D005260:Female; D006801:Humans; D008297:Male; D016577:Pancreaticoduodenectomy / Q000592:standards*; D011183:Postoperative Complications / Q000145:classification*; D011785:Quality Assurance, Health Care; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014481:United States