Presentation Causes of high mortality in colorectal surgery: a review of episodes of care in Veterans Affairs hospitals Kamal M.F. Itani, M.D. a,b, *, Robin Denwood, R.N., M.S.N., M.B.A. c , Tracy Schifftner, M.S. c , Raymond J. Joehl, M.D. d , Creighton Wright, M.D. e , William G. Henderson, Ph.D. c , Ralph G. DePalma, M.D. f a Boston Veterans Affairs Health Care System, 1400 VFW Parkway, West Roxbury, MA 02132, USA b Boston University, One Boston Medical Center Place/C500, Boston, MA 02118, USA c The Veterans Affairs National Surgical Quality Improvement Program, Denver, MS F443/12477 East 19th Ave, PO Box 6508, Aurora, CO 80045, USA d Hines Veterans Affairs Medical Center and Loyola University, 5th and Roosevelt, Hines, IL 60141, USA e Cincinnati Veterans Affairs Medical Center and University of Cincinnati, 3200 Vine St, Cincinnati, OH 45220, USA f Patient Care Services, Department of Veterans Affairs Central Office, 810 Vermont Ave NW, Washington, DC 20420, USA Manuscript received May 17, 2007; revised manuscript August 6, 2007 Presented at the 31st Annual Surgical Symposium of the Association of VA Surgeons, Little Rock, AR, May 10 –12, 2007 Abstract Background: The episode of care for colorectal surgery in 8 outlier Veterans Affairs Hospitals with high mortality and the volume outcome relationship in 118 Hospitals are examined. Methods: A total of 103 deaths were reviewed. Mean age was 74 with 63% of the patients undergoing emergency surgery; 54% of the patients had malignant disease and 21% had metastatic disease. Results: Nineteen percent of the patients had a delay in diagnosis, 22% had delay in surgery and 14% should have received a different surgery usually less radical. In addition, system related issues were identified in 19% of the cases and practitioner related issues in 20% of the cases. The Spearman rank correlation between colorectal surgery volume and unadjusted mortality was 0.114 (P = 0.22). Conclusion: Colorectal surgery death is prevalent in elderly patients undergoing emergency surgery for malignancy or metastatic disease and is not related to hospital volume. Timely diagnosis, less radical surgery while optimizing system based pathways might improve outcome. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Colon; Rectum; Resection; Mortality; System; Structure Although quality-of-care measures for colon and rectal sur- gery have been described, the data relating to structures and processes of care as they pertain to high mortality in this field are sparse. The single indicator associated with lower mortality and higher quality of care revolve mainly around surgeon and hospital volume of similar cases [1,2]. The safety of colon and rectal surgery has improved over time: advances in surgical technique, anesthesia, intensive care, introduction of modern antibiotic treatment, and other sup- portive measures now yield a prevailing mortality rate of approximately 5% [2,3]. Factors predictive of a high peri- operative death rate have been derived specifically for colon and rectal surgery from the National Surgical Quality Im- provement Program (NSQIP) [3,4]. Risk-adjustment meth- ods also have been described to predict complications and deaths along with measures to mitigate some of these risks in elective colorectal surgery [5,6]. In this study, we investigated structures and processes of care contributing to a higher mortality in patients undergo- ing elective colon and rectal surgery in 8 of 118 hospitals within the Veterans Affairs (VA) hospital system. We spe- cifically examined various domains of care spanning the overall episode of care for each patient who died after surgery in facilities detected as high outliers based on actual mortality of 2 times the national average for that time period as well as risk-adjusted mortality. We also examined the relationship between volume of colon and rectal surgery and mortality in the entire VA system. Methods In this study, all patients undergoing colon and rectal resections were selected from the NSQIP database for anal- * Corresponding author. Tel.: +1-857-203-6205; fax: +1-857-203-5549. E-mail address: kitani@med.va.gov The American Journal of Surgery 194 (2007) 639 – 645 0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.08.004