title: Hospital versus individual surgeon's performance in laparoscopic hysterectomy.
abstract: OBJECTIVE
  To compare hospital versus individual surgeon's perioperative outcomes for laparoscopic hysterectomy (LH), and to assess the relationship between surgeon experience and perioperative outcomes.
  
  
  METHODS
  A retrospective analysis of all prospective collected LHs performed from 2003 to 2010 at one medical center was performed. Perioperative outcomes (operative time, blood loss, complication rate) were assessed on both a hospital level and surgeon level using Cumulative Observed minus Expected performance graphs.
  
  
  RESULTS
  A total of 1618 LHs were performed, 16 % total laparoscopic hysterectomies and 84 % laparoscopic supracervical hysterectomies. Overall outcomes included mean (SD±) blood loss 108.9 ± 69.2 mL, mean operative time 95.4 ± 39.7 min and a complication occurred in 76 (4.7 %) of cases. Suboptimal perioperative outcomes of an individual surgeon were not always detected on a hospital level. However, collective suboptimal outcomes were faster detected on a hospital level compared to individual surgeon's level. Evidence of a learning curve is seen; for the first 100 procedures, a decrease in operative time is observed as individual surgeon experience increases. Similarly, the risk of conversion decreases up to the first 50 procedures.
  
  
  CONCLUSIONS
  An individual outlier (i.e., surgeon with consistently suboptimal performance) will not always be detected when monitoring outcome measures only on a hospital level. However, monitoring outcome measures on a hospital level will detect suboptimal performance earlier compared to monitoring only on an individual surgeon's level. To detect performance outliers timely, insight into an individual surgeon's outcome and skills is recommended. Furthermore, an experienced surgeon is no guarantee for acceptable surgical outcomes.
authors.affiliation: Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
authors.forename: Sara R C
authors.initials: SR
authors.lastname: Driessen
authors.affiliation: Department of Obstetrics and Gynecology, University of Heidelberg, INF 440, 69115, Heidelberg, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Wallwiener
authors.affiliation: Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany.
authors.forename: Florin-Andrei
authors.initials: FA
authors.lastname: Taran
authors.affiliation: Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Cohen
authors.affiliation: Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Kraemer
authors.affiliation: Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany.
authors.forename: Christian W
authors.initials: CW
authors.lastname: Wallwiener
authors.affiliation: Department of Medical Statistics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
authors.forename: Erik W
authors.initials: EW
authors.lastname: van Zwet
authors.affiliation: Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tuebingen, Germany.
authors.forename: Sara Y
authors.initials: SY
authors.lastname: Brucker
authors.affiliation: Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. f.w.jansen@lumc.nl.|Department BioMechanical Engineering, Delft University of Technology, PO Box 5, 2600 AA, Delft, The Netherlands. f.w.jansen@lumc.nl.
authors.forename: Frank Willem
authors.initials: FW
authors.lastname: Jansen
mesh_terms: D005260:Female; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D066231:Surgeons
keywords: Case-mix; Experience; Hospital outcome; Laparoscopic hysterectomy; Outcome; Volume