VALIDATING RISK-ADJUSTED SURGICAL OUTCOMES - SITE VISIT ASSESSMENT OFPROCESS AND STRUCTURE

Background: Risk-adjusted mortality and morbidity rates are often used as measures of the quality of surgical care. This study was conducted to determine the validity of risk-adjusted surgical morbidity and mor tality rates as measures of quality of care by assessing the process a nd structure of care in surgical services with higher-than-expected an d lower-than-expected risk-adjusted 30-day mortality and morbidity rat es, Study Design: A structural survey of 44 Veterans Affairs Medical C enter surgical services and site visits to 20 surgical services with h igher-than-expected and lower-than-expected risk-adjusted outcomes wer e conducted, Main outcome measures included assessment of technology a nd equipment, technical competence of staff, leadership, relationship with other services, monitoring of quality of care, coordination of wo rk, relationship with affiliated institutions, and overall quality of care, Results: Surgical services with lower-than-expected risk-adjuste d surgical morbidity and mortality rates had significantly more equipm ent available in surgical intensive care units than did services with higher-than-expected outcomes (4.3 versus 2.9, p < 0.05), Site-visitor ratings of overall quality of care were significantly higher for surg ical services with lower-than-expected morbidity and mortality rates ( 6.1 versus 4.5 for high outliers, p < 0.05); technology and equipment were rated significantly better among low-outlier services (7.1 versus 4.8 for high outliers, p < 0.001). Masked site-visit teams correctly predicted the outlier status (high versus low) of 17 of the 20 surgica l services visited (p < 0.001). Conclusions: Significant differences i n several dimensions of process and structure of the delivery of surgi cal care are associated with differences in risk-adjusted surgical mor bidity and mortality rates among 44 Veterans Affairs Medical Centers. (C) 1997 by the American College of Surgeons.