Complication rates of ostomy surgery are high and vary significantly between hospitals

Abstract

Background: Ostomy surgery is common and has traditionally been associated with high rates of morbidity and mortality, suggesting an important target for quality improvement.

Objective: The purpose of this work was to evaluate the variation in outcomes after ostomy creation surgery within Michigan to identify targets for quality improvement.

Design: This was a retrospective cohort study.

Settings: The study took place within the 34-hospital Michigan Surgical Quality Collaborative.

Patients: Patients included were those undergoing ostomy creation surgery between 2006 and 2011.

Main outcome measures: We evaluated hospital morbidity and mortality rates after risk adjustment (age, comorbidities, emergency vs elective, and procedure type).

Results: A total of 4250 patients underwent ostomy creation surgery; 3866 procedures (91.0%) were open and 384 (9.0%) were laparoscopic. Unadjusted morbidity and mortality rates were 43.9% and 10.7%. Unadjusted morbidity rates for specific procedures ranged from 32.7% for ostomy-creation-only procedures to 47.8% for Hartmann procedures. Risk-adjusted morbidity rates varied significantly between hospitals, ranging from 31.2% (95% CI, 18.4-43.9) to 60.8% (95% CI, 48.9-72.6). There were 5 statistically significant high-outlier hospitals and 3 statistically significant low-outlier hospitals for risk-adjusted morbidity. The pattern of complication types was similar between high- and low-outlier hospitals. Case volume, operative duration, and use of laparoscopic surgery did not explain the variation in morbidity rates across hospitals.

Limitations: This work was limited by its retrospective study design, by unmeasured variation in case severity, and by our inability to differentiate between colostomies and ileostomies because of the use of Current Procedural Terminology codes.

Conclusions: Morbidity and mortality rates for modern ostomy surgery are high. Although this type of surgery has received little attention in healthcare policy, these data reveal that it is both common and uncommonly morbid. Variation in hospital performance provides an opportunity to identify quality improvement practices that could be disseminated among hospitals.

Figure 1. Distribution of ostomy surgery cases for elective (n= 2,667; 62.8%) and emergent procedures (n= 1,583; 37.2%)

Figure 2

Unadjusted morbidity and mortality displayed by emergent status.

Figure 3

Unadjusted morbidity and mortality displayed by procedure type.

Figure 4

Risk-adjusted morbidity rates for all 34 hospitals including 95% confidence intervals. Average percentage (43.8%) is displayed as a horizontal line. Outlier hospitals are identified is their 95% confidence intervals do not intersect with the average morbidity line.