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Predictors of Intraoperative Adverse Events in General Surgery
Michael N. Mavros, MD1,2; Elie P. Ramly, MD1; George C. Velmahos, MD, PhD1, Andreas Larentzakis, MD1,3; D. Dante Yeh, MD1, Peter Fagenholz, MD1; Marc DeMoya, MD1; David R. King, MD1; Jarone Lee, MD, MPH1; Haytham M.A. Kaafarani, MD, MPH1
1Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, MA; 2Department of Surgery, MedStar Washington Hospital Center, Washington, DC; 3Department of Surgery, University of Manchester,UK

Background: Comparing the quality of intraoperative surgical care and the rate of intraoperative adverse events (iAEs) across different hospitals and/or surgeons necessitates adequate risk adjustment. We sought to identify the patient- and procedure-related risk factors for iAEs.

Methods: Our 2007-2012 institutional American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and administrative databases were matched then screened for iAEs using the ICD-9-CM based Patient Safety Indicator “Accidental Puncture/Laceration”. The occurrence of iAEs was confirmed by systematic review of operative reports. Patient co-morbidities were assessed using the ACS-NSQIP variables. Previous abdominal surgery as a variable was determined using the CPT codes for adhesiolysis. Operative complexity was determined using relative value units (RVUs). Multivariate models were constructed to identify independent predictors of iAEs. Sensitivity analyses were performed in a uniform sample of operations.

Results: Of a total of 9292 general surgery procedures, 218 iAEs were confirmed. The median patient age was 56 years; 54% were female. In multivariable regression analyses, previous surgery [adjusted OR=2.34, 95% CI: 1.71 – 3.21, p<0.001], higher operative complexity (3rd vs. 1st RVU IQR: OR=3.36 (1.66 – 6.78), p<0.001; 4th vs 1st RVU IQR: OR=5.97 (3.01 – 11.86), p<0.001], and “open” surgical approach [vs. laparoscopic; OR=2.04 (1.39 – 3.01), p<0.001] independently predicted the occurrence of iAEs. Sensitivity analyses confirmed previous surgery and higher operative complexity as independent predictors of iAEs.

Conclusion: Previous surgery and higher operative complexity significantly increase the risk of iAEs. Any attempts at benchmarking the quality of intraoperative surgical care needs to risk adjust for these factors.

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