Original ArticleThe Postoperative Morbidity Survey was validated and used to describe morbidity after major surgery
Introduction
Calls for increased clinical safety and accountability after high profile health care scandals, the drive to give patients a choice between different health care providers, and the linkage of funding to measured results have driven the outcomes reporting agenda forward. Cardiac surgery has led the way in the reporting of outcomes after surgery [1], [2], [3] and other surgical specialties are now following [4]. These initiatives are limited by the lack of validated instruments for describing the variety of outcomes occurring to individual patients. The measures currently used to assess outcome after surgery have significant limitations.
Mortality is the most commonly cited variable, but the low event rate after elective surgery limits its applicability as a general outcome measure. Length of hospital stay is known to be affected by medical and nonmedical factors and therefore functions as a hybrid measure of process and outcome [5], [6], [7], [8], [9]. Recording of perioperative morbidity has hitherto been limited: a recent systematic review of the measurement and monitoring of surgical adverse events found inconsistency in the quality of reporting of postoperative adverse events limiting accurate comparison of rates over time and between institutions [10]. A reliable and valid index of short-term postoperative morbidity would be of enormous value in quality of care, prognostic, and effectiveness research.
The Postoperative Morbidity Survey (POMS) is the only published prospective method for describing short-term morbidity after major surgery [11]. The POMS was designed with two guiding principles. First, it should only identify morbidity of a type and severity that could delay discharge from hospital. Second, the data collection process should be as simple as possible so that large numbers of patients can be routinely screened. Following on from these principles, a measure was produced that focused on easily collectable indicators of clinically important dysfunction in key organ systems. The indicators are obtainable from routinely available sources and do not require special investigations. These sources include observation charts, medication charts, patient notes, routine blood test results, and direct questioning and observation of the patient. Crucially, the indicators define morbidity in terms of clinically important consequences rather than traditional diagnostic categories.
Item generation was achieved through a three-stage process [11]. First, investigators collected information directly from patients, nurses, and doctors using open questions to identify reasons why the patients remained in hospital after surgery. Second, the responses obtained were categorized into domains of morbidity type. Thresholds were set for individual domains to achieve the primary goal of identifying morbidity of a type and severity that could delay discharge from hospital. Finally, the derived survey was reviewed and amended by an international consensus panel of anesthesiologists and surgeons. The POMS (Table 1) contains 18 items that address nine domains of postoperative morbidity. For each domain, either presence or absence of morbidity is recorded on the basis of objective criteria. The POMS is starting to be used in outcomes research [12] and in effectiveness research [13].
The aims of this study were to describe the level and pattern of short-term postoperative morbidity in a UK teaching hospital and to establish the reliability and validity of the POMS in patients undergoing elective major surgery.
Section snippets
Methods
All adult patients (aged 18 years or above) undergoing major elective surgery at the Middlesex NHS Hospital (London, UK) between July 1, 2001 and September 30, 2003 were eligible for inclusion in this prospective cohort study. Recruitment was interrupted during periods of study nurse annual leave.
Major elective surgery was defined as procedures expected to last more than 2 hours or with an anticipated blood loss greater than 500 mL. The following procedures were included: orthopedic surgery
Characteristics of study population
Of the 706 patients, 450 (63.7%) who were candidates for inclusion were enrolled into the study. The main reasons for nonenrollment were lack of preoperative consent (139 patients), communication problems (47 patients), and enrollment in other studies (37 patients). One of the enrolled patients withdrew after provision of consent, one was found to be participating in an interventional study, one was withdrawn by the attending consultant, and eight did not have surgery.
Patient and perioperative
Summary of findings
In this first use of the POMS in a UK setting, gastrointestinal, infectious, pain-related, pulmonary, and renal problems were the most common sources of morbidity after major surgery. Many patients remained in hospital despite having no morbidity, but no patient free of morbidity as defined by the POMS was found to have a morbidity-related reason for remaining in hospital: the POMS captured all relevant morbidity in inpatients. A variety of nonmedical reasons were identified as being
Conclusions
The POMS identified gastrointestinal, infectious, pain-related, pulmonary, and renal problems as the most common sources of morbidity after major surgery in a UK setting. Many patients remain in hospital despite absence of postoperative morbidity as defined by the POMS. Screening for postoperative morbidity using the POMS may be useful to identify patients remaining in acute hospital beds unnecessarily. The POMS may have utility as a tool for recording bed occupancy and for modeling bed
References (49)
- et al.
The Veterans Affairs Continuous Improvement in Cardiac Surgery Study
Ann Thorac Surg
(1994) - et al.
Risk stratification using the Society of Thoracic Surgeons Program
Ann Thorac Surg
(1994) - et al.
Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study
J Am Coll Surg
(1997) - et al.
Appropriateness of hospital utilisation in Italy
Public Health
(2000) - et al.
Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery
Br J Anaesth
(2005) - et al.
Powering our way to the elusive side effect: a composite outcome ‘basket’ of predefined designated endpoints in each organ system should be included in all controlled trials
J Clin Epidemiol
(2005) - et al.
A comparative contrast of clinimetric and psychometric methods for constructing indexes and rating scales
J Clin Epidemiol
(1992) - et al.
A discussion on the role of clinimetrics and the misleading effects of psychometric theory
J Clin Epidemiol
(2005) - et al.
Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery
Br J Anaesth
(2005) - et al.
Adverse impact of surgical site infections in English hospitals
J Hosp Infect
(2005)
National nosocomial infection surveillance system-based study in Iran: additional hospital stay attributable to nosocomial infections
Am J Infect Control
Assessment of prolonged hospital stay attributable to surgical site infections using appropriateness evaluation protocol
Am J Infect Control
Continuous assessment and improvement in quality of care. A model from the Department of Veterans Affairs Cardiac Surgery
Ann Surg
Risk-adjusted surgical outcomes
Annu Rev Med
Appropriateness of admissions and hospitalization days in an acute-care teaching hospital
Rev Epidemiol Sante Publique
Appropriateness of hospital use: an overview of Italian studies
Int J Qual Health Care
Medical appropriateness of hospital utilization: an overview of the Swiss experience
Int J Qual Health Care
The measurement and monitoring of surgical adverse events
Health Technol Assess
The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery
Anesth Analg
Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation
Arch Surg
New classification of physical status
Anesthesiology
POSSUM: a scoring system for surgical audit
Br J Surg
A coefficient of agreement for nominal scales
Psychol Meas
The theory of the estimation of test reliability
Psychometrika
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