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Surgical Outcomes in Canada and the United States: An Analysis of the ACS-NSQIP Clinical Registry

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Abstract

Background

There has been longstanding uncertainty over whether lower healthcare spending in Canada might be associated with inferior outcomes for hospital-based care. We hypothesized that mortality and surgical complication rates would be higher for patients who underwent four common surgical procedures in Canada as compared to the US.

Design, Setting, and Participants

We conducted a retrospective cohort study of all adults who underwent hip fracture repair, colectomy, pancreatectomy, or spine surgery in 96 Canadian and 585 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) between January 1, 2015 and December 31, 2019. We compared patients with respect to demographic characteristics and comorbidity. We then compared unadjusted and adjusted outcomes within 30-days of surgery for patients in Canada and the US including: (1) Mortality; (2) A composite constituting 1-or-more of the following complications (cardiac arrest; myocardial infarction; pneumonia; renal failure/; return to operating room; surgical site infection; sepsis; unplanned intubation).

Results

Our hip fracture cohort consisted of 21,166 patients in Canada (22.3%) and 73,817 in the US (77.7%), for colectomy 21,279 patients in Canada (8.9%) and 218,307 (91.1%), for pancreatectomy 873 (7.8%) in Canada and 12,078 (92.2%) in the US, and for spine surgery 14,088 (5.3%) and 252,029 (94.7%). Patient sociodemographics and comorbidity were clinically similar between jurisdictions. In adjusted analyses odds of death was significantly higher in Canada for two procedures (colectomy (OR 1.22; 95% CI 1.044–1.424; P = .012) and pancreatectomy (OR 2.11; 95% CI 1.26–3.56; P = .005)) and similar for hip fracture and spine surgery. Odds of the composite outcome were significantly higher in Canada for all 4 procedures, largely driven by higher risk of cardiac events and post-operative infections.

Conclusions

We found evidence of higher rates of mortality and surgical complications within 30-days of surgery for patients in Canada as compared to the US.

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Author information

Author notes

  1. Peter Cram

    Present address: University of Texas Medical Branch, Galveston, TX, USA

Authors and Affiliations

  1. Department of Medicine, University of Toronto, Toronto, ON, Canada

    Peter Cram

  2. Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON, Canada

    Peter Cram

  3. ICES, Toronto, ON, Canada

    Peter Cram

  4. American College of Surgeons, Chicago, IL, USA

    Mark E. Cohen, Clifford Ko & Bruce Hall

  5. UCLA Department of Surgery, Los Angeles, CA, USA

    Clifford Ko

  6. Los Angeles VA Medical Center, Los Angeles, CA, USA

    Clifford Ko

  7. Department of Health Care Policy, Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, USA

    Bruce E. Landon

  8. Department of Surgery, School of Medicine, Washington University, St Louis, MO, USA

    Bruce Hall

  9. St Louis VA Medical Center, St Louis, MO, USA

    Bruce Hall

  10. BJC Healthcare, St Louis, MO, USA

    Bruce Hall

  11. Department of Surgery, University of Toronto, Toronto, Canada

    Timothy D. Jackson

  12. Division of General Surgery, University Health Network, Toronto, ON, Canada

    Timothy D. Jackson

Authors
  1. Peter Cram
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  2. Mark E. Cohen
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  3. Clifford Ko
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  4. Bruce E. Landon
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  5. Bruce Hall
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  6. Timothy D. Jackson
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Correspondence to Peter Cram.

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Appendices

Appendix 1

See Table 2

Table 2 List of codes used for identification of hip fractures, colectomy, pancreatectomy, and spine surgery
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Appendix 2

See Table 3

Table 3 Unadjusted outcomes for hip fracture, colectomy, pancreatectomy, and spine surgery performed in Canada and the USA
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Appendix 3

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Table 4 Odds of adverse outcomes in Canada (USA as reference) for each surgical procedure and outcome in models including and excluding ASA class from models
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Cram, P., Cohen, M.E., Ko, C. et al. Surgical Outcomes in Canada and the United States: An Analysis of the ACS-NSQIP Clinical Registry. World J Surg 46, 1039–1050 (2022). https://doi.org/10.1007/s00268-022-06444-w

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