title: The 30-day versus in-hospital and 90-day mortality after esophagectomy as indicators for quality of care.
abstract: OBJECTIVE
  To describe causes of death in the first year after esophagectomy and determine the time frame that should be used for measurement of quality of surgery. A case-mix adjustment model was developed for the comparison between hospitals.
  
  
  BACKGROUND
  The time period in which postoperative mortality should be measured as a performance indicator is debated.
  
  
  METHODS
  Cause of death was identified for patients in a tertiary referral hospital who died within 1 year after surgery and classified as surgery related or not surgery related. Sensitivity and specificity for detecting deaths related to surgery were calculated for different periods of follow-up. Case-mix adjustment models for 30-day mortality (30DM), in-hospital mortality, and 90-day mortality (90DM) were developed.
  
  
  RESULTS
  In total, 1282 patients underwent esophagectomy. 30DM was 2.9%, the in-hospital mortality rate was 5.1% and 90DM was 7%. Beyond 30 days, a substantial number of deaths were related to the operation, especially due to anastomotic leakage. Postdischarge nononcological mortality was most frequently caused by sudden death. One in 5 patients died because of recurrent disease, being the most important threat in the first year after surgery. The 30DM had a sensitivity for detecting surgery-related deaths of 33% and a specificity of 100%. The 90DM had a sensitivity of 74% and a specificity of 96%.
  
  
  CONCLUSIONS
  A period of postoperative follow-up longer than 30 days needs to be considered when comparing surgical performance between institutes. In the case-mix adjustment model for 90DM, no other variables have to be taken into account compared to those involved in 30DM.
authors.affiliation: Departments of *Surgery and †Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: A Koen
authors.initials: AK
authors.lastname: Talsma
authors.forename: Hester F
authors.initials: HF
authors.lastname: Lingsma
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: Bas P L
authors.initials: BP
authors.lastname: Wijnhoven
authors.forename: J Jan B
authors.initials: JJ
authors.lastname: Van Lanschot
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D003953:Diagnosis-Related Groups; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000401:mortality* / Q000592:standards*; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D018570:Risk Assessment; D012307:Risk Factors