The Complication of Complication Rates

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This week, we welcome guest blogger Dr. Donald Fry, an academic surgeon and healthcare quality expert, to address the complex problem of measuring complications and explain why prolonged risk-adjusted length of stay is one of the strongest indicators of quality.


I have spent a great deal of my career over the last three decades looking at issues related to complication rates. One thing that has become clear is that there’s nothing clear about calculating complication rates.

As an industry, we have been collectively looking at complications for almost as long as surgical procedures have been done, but the cruel reality in 2016 is that we still do not know the accurate estimate of complication rates in surgical care. How is this possible? 


It’s complicated

To begin with, individual hospitals code very different rates of complications for the same operation and coded complications have no severity indicator. Should a positive urine culture that is quickly managed with prompt antibiotic management be given the same equivalency as postoperative urinary tract sepsis? One will never know from the discharge codes because they are commonly given the same coded designation. Furthermore, with Medicare Part A hospital payments, coding certain complications has the perverse incentive of increasing revenue for an episode of care.

Despite poor definition of actual complication rates, there is a rush by many patient advocacy groups to publish complication rates by hospitals and by clinicians in the hopes that this represents discriminating information for the identification of best and worst performance.

Do complication rates tell the truth?

When asking surgeons: “what is your complication rate?” One will almost certainly get an answer that is removed from reality. It’s unclear whether that is because surgeons are making gross estimates, have selective forgetfulness, are intentionally deceptive, or simply do not know. It’s often the case that postoperative patients are seen in emergency departments or hospitals other than where the surgical care was delivered, making it difficult for surgeons to track adverse outcomes. Compounding this is the fact that there are no standardized objective measurements for surgical site and other complications of care.

The disconnect extends to research results. Several years ago, I published a study of elective colon surgery from the National Inpatient Sample from the Healthcare Cost and Utilization Project. The surgical site infection rate coded in the discharge abstracts was 3.9% in our study, which I did not believe and stated as such in the manuscript. For roughly the same time period, the National Healthcare Surveillance Network reported surgical site infection rates in colon surgery between 4-9 % depending upon the risk profile of their study population. The National Surgical Quality Improvement Project reported an overall rate of about 9-11 % in the same procedure. For additional prospective, during the clinical trial for Ertapenem, investigators reported surgical site infections for elective colon surgery were greater than 20%.

Clearly different definitions, collection and analysis approaches were used, but the varying results beg the questions: “what is the real complication rate?” and “Is complication rate really the right metric to use to describe surgical outcome or quality?”

A better measure: length of stay

These complexities and disconnects are why I have chosen to rely on prolonged, risk-adjusted length of stay as a proxy for complication rates. At MPA, we found that the length of stay is a much more accurate representation of complications and severity than simple percentage of occurrence. We are not alone, there is an abundance of documentation by other investigators showing a link between long length of stay and significant complications of care. Additionally, the metric is currently in use by major insurance companies, hospitals, and consumer advocacy groups such as Consumer Reports.

Below are a few selected publications I wrote on this topic, which give additional evidence and data that supports the use of length of stay:

Conclusion: Prolonged, risk-adjusted length of stay is one of the best available metric for adverse events available and should be used as a measure of healthcare quality.


Donald E. Fry, MD, is the executive vice-president of Clinical Outcomes Management at MPA Healthcare Solutions, an adjunct professor of surgery at the Northwestern University Feinberg School of Medicine, and editor-in-chief of the journal Surgical Infections. He is the former Chair of Surgery at the University of New Mexico School of Medicine, and has maintained a career interest in surgical infections. 

A version of this blog was originally published at the American Journal of Medical Complication and can be found here.