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Dr Alex Almoudaris and colleagues from the United Kingdom evaluated the overall performance of English colorectal cancer surgical units identified as outliers for a single quality measure of 30 day inhospital mortality. The team evaluated 144,542 patients that underwent primary major colorectal cancer resection between 2000/2001 and 2007/2008 in 149 English National Health Service units were included from hospital episodes statistics. The team evaluated 30 day inhospital mortality, length of stay, unplanned readmission within 28 days, reoperation, failure to rescue-surgical and abdominoperineal excision rates. Institutional performance was evaluated across all other domains for institutions deemed outliers for 30 day mortality. ‘Acceptable’ performance was defined if units appeared under the upper 2 SD limit. The team of doctors noted that results 5 high mortality outlier units, and 15 low mortality outlier units were identified.  | | 1 of the 15 low mortality outlier units exceeded 3 SD for substandard performance | | Gut |
Of the 5 high mortality outlier units, 2 were substandard performance outliers on another metric. The research team found that a further 2 high mortality outlier institutions exceeded the second but not the third SD limits for substandard performance on other outcome metrics. The team noted that 1 of the 15 low mortality outlier units exceeded 3 SD for substandard performance. The doctors found that one low mortality outlier institution exceeded the second but not the third SD control limits for high reoperation rates. Institutional mortality correlated with failure to rescue-surgical and reoperations. Dr Almoudaris' concludes, "Performance appraisal in colorectal surgery is complex and dependent on stakeholder perspective." "Benchmarking units solely on a single performance measure is over simplistic and potentially hazardous." "A global appraisal of institutional outcome is required to contextualise performance."
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