Application of a simple, affordable quality metric tool to colorectal, upper gastrointestinal, hernia, and hepatobiliary surgery patients: the HARM score
Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties.
From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien–Dindo classification.
We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2–< 3, 3–4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien–Dindo classification.
The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.
KeywordsSurgical outcomes Quality Colorectal Hepatobiliary
This study was supported by a SAGES Research Grant.
All authors made substantial contributions to conception and design, and/or acquisition of data, and/or analysis and interpretation of data; participated in drafting the article or revising it critically for important intellectual content and gave final approval of the version to be submitted and any revised version to be published.
Compliance with ethical standards
Dr. Samuel F. Hohmann is employed by Vizient as a Research Analytics Director, Dr. Scott R. Steele has consulted to Medtronic and Ethicon, Dr. Conor P. Delaney has consulted to Merck, Ethicon, Trans-Enterix and Recro-Pharma, Dr. Justin Brady, Dr. Bona Ko, Dr. Benjamin P. Crawshaw, Dr. Jennifer A. Leinicke, and Dr. Knut M. Augestad have no conflicts of interest or financial ties to disclose.
- 1.Cologne KG, Keller DS, Liwanag L, Devaraj B, Senagore AJ (2015) Use of the American College of Surgeons NSQIP surgical risk calculator for laparoscopic colectomy: how good is it and how can we improve it? J Am Coll Surg 220:281–286. https://doi.org/10.1016/j.jamcollsurg.2014.12.007 CrossRefPubMedGoogle Scholar
- 3.Edmiston CE, Spencer M, Lewis BD, Brown KR, Rossi PJ, Henen CR, Smith HW, Seabrook GR (2011) Reducing the risk of surgical site infections: did we really think SCIP was going to lead us to the promised land? Surg Infect (Larchmt) 12:169–177. https://doi.org/10.1089/sur.2011.036 CrossRefGoogle Scholar
- 9.O’Brien SM, Shahian DM, DeLong ER, Normand SLT, Edwards FH, Ferraris VA, Haan CK, Rich JB, Shewan CM, Dokholyan RS, Anderson RP, Peterson ED (2007) Quality measurement in adult cardiac surgery: part 2-statistical considerations in composite measure scoring and provider rating. Ann Thorac Surg. https://doi.org/10.1016/j.athoracsur.2007.01.055 Google Scholar
- 13.Crawshaw BP, Keller DS, Brady JT, Augestad KM, Schiltz NK, Koroukian SM, Navale SM, Steele SR, Delaney CP (2016) The HARM score for gastrointestinal surgery: application and validation of a novel, reliable and simple tool to measure surgical quality and outcomes. Am J Surg. https://doi.org/10.1016/j.amjsurg.2016.11.007 PubMedGoogle Scholar
- 14.Sutton JM, Hayes AJ, Wilson GC, Quillin RC, Wima K, Hohmann S, Paquette IM, Sussman JJ, Ahmad SA, Shah SA, Abbott DE (2014) Validation of the University HealthSystem Consortium administrative dataset: concordance and discordance with patient-level institutional data. J Surg Res 190:484–490. https://doi.org/10.1016/j.jss.2014.03.044 CrossRefPubMedGoogle Scholar
- 15.Lipshutz AKM, Feiner JR, Grimes B, Gropper MA (2016) Predicting mortality in the intensive care unit: a comparison of the University Health Consortium expected probability of mortality and the mortality prediction model III. J Intensive Care 4:35. https://doi.org/10.1186/s40560-016-0158-z CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Vizient Clinical Database and Resource Manager (2017). https://www.vizientinc.com/Our-solutions/Clinical-Solutions/Clinical-Data-Base-and-Resource-Manager. Accessed 17 May 2017
- 19.Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Young MT, Crawshaw BP, Phelan MJ, Mills SD, Carmichael JC, Pigazzi A, Delaney CP, Stamos MJ (2014) Expanding the HospitAl stay, Readmission and Mortality (HARM) score: measuring quality and outcomes in colorectal and gastrointestinal surgery. J Am Coll Surg 219:e150–e151. https://doi.org/10.1016/j.jamcollsurg.2014.07.791 CrossRefGoogle Scholar
- 22.Billeter AT, Polk HC, Hohmann SF, Qadan M, Fry DE, Jorden JR, McCafferty MH, Galandiuk S (2012) Mortality after elective colon resection: the search for outcomes that define quality in surgical practice. J Am Coll Surg 214:436–443. https://doi.org/10.1016/j.jamcollsurg.2011.12.018 CrossRefPubMedGoogle Scholar