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Risk-Adjusted Monitoring of Binary Surgical Outcomes

Department of Statistics and Actuarial Sciences, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1

Richard J. Cook, PhD

Department of Statistics and Actuarial Sciences, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1

Vern T. Farewell, PhD

Department of Statistical Sciences, University College, London, United Kingdom

A graphical procedure suitable for prospectively monitoring surgical performance is proposed. The approach is based on accumulating evidence from the outcomes of all previous surgical patients in a series using a new type of cumulative sum chart. Cumulative sum procedures are designed to "signal" if sufficient evidence has accumulated that the surgical failure rate has changed substantially. In this way, the chart rapidly detects deterioration (or improvement) in surgical performance while not overreacting to the expected fluctuations due to chance. Through the use of a likelihood-based scoring method, the cumulative sum procedure is adapted so that it adjusts for the surgical risk of each patient estimated preoperatively. The procedure is therefore applicable in situations where it is desirable to adjust for a mix of patients. Signals of the chart lead to investigations of the cause and to the timely introduction of remedial measures designed to avoid unnecessary future failures.

Key Words: cumulative sum • monitoring performance • patient mix • risk factors • surgical outcomes

Medical Decision Making, Vol. 21, No. 3, 163-169 (2001)
DOI: 10.1177/0272989X0102100301


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