P13 Understanding unwarranted variation in surgical outcome - a Delphi study with perioperative professionals.

Abstract

Abstract Introduction Current assessment of perioperative risk relies on patient and surgical factors. However, risk stratification is imperfect and significant unwarranted variation in outcome persists. We sought to identify factors that may influence outcome, but which are under-represented in the literature. Methods We used process mapping of stereotyped surgical pathways to identify participants for a multidisciplinary, three round Delphi across two United Kingdom hospitals. A three-round Delphi of 91 stakeholders, from 23 professional groups was conducted. Using a 5-point Likert-scale consensus was defined as a median of >3.5 or <2.5 with an interquartile range of <1. Results Response rates were Round one: 51%, round two: 38%, round three: 19%. In round one free text panel suggestions were combined with variables from existing risk scores. This yielded 410 variables. With new suggestions from round two, 468/519 (90%) of the statements ultimately presented to the panel reached consensus. These included patient factors (such as ethnicity and socio-economic status); organisational or process factors related to the hospital (such as policies, staffing, and organisational culture). 66/160 (41%) of the new suggestions did not feature in systematic reviews of perioperative risk scores or key process indicators. No factor categorised as ‘organisational’ (such as organisational culture or external pressures) was present in any examined perioperative risk score. Conclusion We identified broader insights into additional factors that may underlie variation in outcome based on the expertise of perioperative professionals. These results could support future research into how organisational structure and performance influences patient outcome. Take-home message Perioperative professionals view factors outside of patient and clinician control as relating to surgical outcome. Such factors appear to be absent from many commonly used risk stratification tools.