Quality Assurance and Benchmarking for Radical Cystectomy: Monitoring Early Complications and Mortality Using Cumulative Summation Charts

Abstract

Cumulative summation is one method for quality assurance that has recently been adapted to the medical field to monitor any binary surgical outcomes on an ongoing basis. In this study we used cumulative summation charts for quality assurance in radical cystectomies. Cumulative summation charts were generated from prospectively collected data for the first 150 radical cystectomies performed by a single surgeon from 2001 to 2007. Overall and disease specific survival were estimated using the Kaplan-Meier actuarial methodology and stratified by pathological stage. Based on a literature review acceptable rates were identified as death 0.3% to 4%, ureterointestinal leak 0.3% to 1%, unplanned reoperation 2.3% to 17%, myocardial infarction 0.3% to 2% and pulmonary embolism 0.4% to 2%. Median followup was 16 months. There were 12, 12, 41, 26, 25 and 34 patients with pTis, pT1, pT2, pT3, pT4 and pN+ disease, respectively. The 5-year disease specific survival for less than pT2, pT2, pT3, pT4 and pN+ was 92%, 90%, 60%, 51% and 30%, respectively. The occurrence of postoperative death, rectal injury, ureterointestinal anastomotic leak, immediate reoperation, myocardial infarction and pulmonary embolus for the 150 patients was 1, 0, 3, 2, 2 and 3, respectively. Cumulative summation graphs allowed a visual guide to the key performance indicators. Using cumulative summation surgeons can continuously identify if their morbidity or mortality rates are approaching benchmark limits. This approach may provide more timely information when alterations in surgical technique, patient selection and perioperative care should be considered if benchmark limits are being approached for a variety of surgical outcomes.