Journal Watch Surgical Skill and Complication Rates After Bariatric Surgery Birkmeyer J.D., Finks J.F., O'Reilly A., et al. N Engl J Med. 2013;369:1434-42. http://dx.doi.org/10.1056/ NEJMsa1300625.
SUMMARY
T
his trial was designed to measure individual surgeon skill and its relationship to patient outcomes. Building on an established statewide collaborative improvement program in Michigan (Michigan Bariatric Surgery Collaborative), 20 surgeons from across the state participated in the study by submitting a representative videotape of themselves performing a laparoscopic gastric bypass. This is the most common bariatric surgery and is considered relatively complex, with a higher complication rate than alternative procedures. The videos were edited to reduce them to just the critical portions of the surgery (25-40 minutes), and a panel of 33 other bariatric surgeons in Michigan scored the videos on a scale of 1-5 (with 3 reflecting the skill of an average practicing bariatric surgeon and higher scores indicating more advanced skill) for technical skill. This was done in a blinded fashion, and at least 10 surgeons rated each video. The rating was conducted using an instrument modified slightly from the “Objective Structured Assessment of Technical Skills”, which has been validated for use in bariatric surgery. The skill rating was then compared with the riskadjusted complication rates for each surgeon, which were derived from a prospective, externally audited, clinical outcomes registry involving 10,343 patients between 2006 and 2012. Surgical complications included surgical-site infection, dehiscence, abdominal abscess, anastomotic leak or stricture, bowel obstruction, and hemorrhage. Medical complications as well as 30-day rates of death, unplanned reoperation, readmission, and emergency department visits were also captured. The mean surgical skill rating ranged from 2.6 to 4.8 across the 20 surgeons. Surgical skill correlated strongly with procedure volume but not with years in bariatric surgery practice, completion of a corresponding fellowship, or practice at a teaching vs nonteaching hospital. When divided into quartiles, the bottom quartile by skill rating (5 surgeons with a mean rating of 2.9) had a higher complication rate (14.5% vs 5.2%; P
SUMMARY
T
his trial was designed to measure individual surgeon skill and its relationship to patient outcomes. Building on an established statewide collaborative improvement program in Michigan (Michigan Bariatric Surgery Collaborative), 20 surgeons from across the state participated in the study by submitting a representative videotape of themselves performing a laparoscopic gastric bypass. This is the most common bariatric surgery and is considered relatively complex, with a higher complication rate than alternative procedures. The videos were edited to reduce them to just the critical portions of the surgery (25-40 minutes), and a panel of 33 other bariatric surgeons in Michigan scored the videos on a scale of 1-5 (with 3 reflecting the skill of an average practicing bariatric surgeon and higher scores indicating more advanced skill) for technical skill. This was done in a blinded fashion, and at least 10 surgeons rated each video. The rating was conducted using an instrument modified slightly from the “Objective Structured Assessment of Technical Skills”, which has been validated for use in bariatric surgery. The skill rating was then compared with the riskadjusted complication rates for each surgeon, which were derived from a prospective, externally audited, clinical outcomes registry involving 10,343 patients between 2006 and 2012. Surgical complications included surgical-site infection, dehiscence, abdominal abscess, anastomotic leak or stricture, bowel obstruction, and hemorrhage. Medical complications as well as 30-day rates of death, unplanned reoperation, readmission, and emergency department visits were also captured. The mean surgical skill rating ranged from 2.6 to 4.8 across the 20 surgeons. Surgical skill correlated strongly with procedure volume but not with years in bariatric surgery practice, completion of a corresponding fellowship, or practice at a teaching vs nonteaching hospital. When divided into quartiles, the bottom quartile by skill rating (5 surgeons with a mean rating of 2.9) had a higher complication rate (14.5% vs 5.2%; P
