title: Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation.
abstract: OBJECTIVE
  To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.
  
  
  BACKGROUND
  Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk.
  
  
  METHODS
  This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance.
  
  
  RESULTS
  There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment.
  
  
  CONCLUSIONS
  This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.
authors.affiliation: *Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania†Department of Surgery, Mayo Clinic, Jacksonville, Florida‡Department of Surgery, University of Calgary, Calgary, Canada§Department of Surgery, University of Verona, Verona, Italy¶Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana||Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee**Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania††Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio‡‡Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts§§Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama¶¶Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts||||Department of Surgery, Baylor College of Medicine, Houston, Texas***Department of Surgery, University of Florida College of Medicine, Gainesville, Florida†††Department of Surgery, Yale School of Medicine, New Haven, Connecticut‡‡‡Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: McMillan
authors.forename: Sameer
authors.initials: S
authors.lastname: Soi
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.forename: Claudio
authors.initials: C
authors.lastname: Bassi
authors.forename: Joal D
authors.initials: JD
authors.lastname: Beane
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Behrman
authors.forename: Adam C
authors.initials: AC
authors.lastname: Berger
authors.forename: Mark
authors.initials: M
authors.lastname: Bloomston
authors.forename: Mark P
authors.initials: MP
authors.lastname: Callery
authors.forename: John D
authors.initials: JD
authors.lastname: Christein
authors.forename: Elijah
authors.initials: E
authors.lastname: Dixon
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Drebin
authors.forename: Carlos Fernandez-Del
authors.initials: CF
authors.lastname: Castillo
authors.forename: William E
authors.initials: WE
authors.lastname: Fisher
authors.forename: Zhi Ven
authors.initials: ZV
authors.lastname: Fong
authors.forename: Michael G
authors.initials: MG
authors.lastname: House
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Hughes
authors.forename: Tara S
authors.initials: TS
authors.lastname: Kent
authors.forename: John W
authors.initials: JW
authors.lastname: Kunstman
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Malleo
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Miller
authors.forename: Ronald R
authors.initials: RR
authors.lastname: Salem
authors.forename: Kevin
authors.initials: K
authors.lastname: Soares
authors.forename: Vicente
authors.initials: V
authors.lastname: Valero
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wolfgang
authors.forename: Charles M
authors.initials: CM
authors.lastname: Vollmer
mesh_terms: D021441:Carcinoma, Pancreatic Ductal / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D010185:Pancreatic Fistula / Q000453:epidemiology*; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology*; D019984:Quality Indicators, Health Care; D012044:Regression Analysis; D012189:Retrospective Studies; D018570:Risk Assessment