Financial Rx for physicians.

It's no secret that doctors are facing more financial struggles than ever before. Thanks to skyrocketing malpractice insurance premiums, slashed or stagnant reimbursement rates, and an aging population that will need more care, physicians across the country are struggling to stay financially solvent. This article outlines some simple steps that physicians can take to keep their personal and professional lives financially healthy. Not only will these suggestions help ease the difficulties of the present, but they will also help doctors plan for the future.

Intra-operative parathyroid hormone monitoring in patients with parathyroid cancer.

BACKGROUND: Intra-operative parathyroid hormone (PTH) monitoring (IPM) is 97% accurate in predicting postoperative eucalcemia in sporadic primary hyperparathyroidism (SPHPT). However, its usefulness in parathyroid cancer has not been demonstrated. This study reports IPM accuracy during surgical resections for parathyroid cancer. METHODS: Eight of 556 consecutive patients with SPHPT underwent parathyroidectomy using IPM and had parathyroid cancer. Operative success was defined as eucalcemia > six months and operative failure/persistent cancer as hypercalcemia within six months of parathyroidectomy. The IPM criterion for operative success was defined as a >50% decrease of peripheral PTH levels from the highest either pre-incision or pre-excision values, 10 minutes after resection. RESULTS: In eight patients, 11 operations were performed. Ten operations (91%) resulted in >50% intra-operative PTH decrease. However, in only seven (70%) of these resections, eucalcemia was achieved for >6 months with five of these seven (71%) procedures being initial en bloc resections. The remaining 3/10 (30%) operations with >50% intra-operative PTH decrease resulted in operative failures. In the last operation, intraoperative parathormone monitoring (IPM) correctly predicted operative failure. IPM sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy in predicting outcome were 100, 40, 70, 100, and 75%, respectively. CONCLUSIONS: IPM with the criterion of >50% PTH drop from the highest level is less accurate in predicting operative success in parathyroid cancer when compared to SPHPT. A >50% intra-operative PTH level decrease in patients with parathyroid cancer, particularly in reoperative cases, is less predictive of complete resection. The initial recognition of this disease followed by proper resection remains essential in the treatment of parathyroid cancer.

The application of the Things I Worry About Scale to a sample of at-risk American adolescents: an examination of psychometric properties.

To date, published studies regarding the Things I Worry About Scale have been conducted exclusively in Northern Ireland and have included relatively homogeneous samples of students. The present study reexamined the psychometric properties of the scale using data collected from a sample of at-risk adolescents in the United States. The factor structure of the instrument was examined to determine the reliability of the instrument with a culture other than that with which the instrument was developed, and salient group differences were identified and discussed. The cross-cultural applicability of the instrument and the stability of the factor structure were explored and found to be relatively robust. However, differences were identified which were specifically related to the emergence of a highly salient component representing a very pessimistic view of what the future held. The results suggest the need for confirmatory factor analytical studies and further examination of the utility of the instrument with diverse populations.

Salient worries of at-risk youth: needs assessment using the things I worry about scale.

At-risk students in the southern United States were surveyed using the Things I Worry About Scale. From their responses, 13 categories were ranked from most salient to least salient. The rank order obtained in the present study was compared to that obtained with a normative group of youths in Northern Ireland. The two rank orders were found to be significantly correlated. The relatedness of the rank orderings of the two seemingly disparate samples suggests the universality of the Things I Worry About Scale. The merits of using the scale as part of a comprehensive needs assessment are discussed.

"Limited" parathyroidectomy in geriatric patients.

OBJECTIVE: Elderly patients with primary hyperparathyroidism accompanied by other diseases are often denied referral for parathyroidectomy because of the associated risks of general anesthesia and bilateral neck exploration. However, marked symptomatic improvement is recognized after successful parathyroidectomy. The purpose of this report is to examine the postoperative outcome of geriatric patients undergoing "limited" parathyroidectomy. METHODS: Since 1993, 291 consecutive patients with primary hyperparathyroidism were treated with "limited" parathyroidectomy guided by preoperative localization and intraoperative parathyroid hormone assay. In 34 of the procedures (29 initial, 5 reoperations), the patient was 75 years or older; these patients are the subject of this report. Patients were followed up for serum calcium, parathyroid hormone levels, and symptomatology. RESULTS: Twenty-seven patients were followed up for 31 (range 6-84) months: all remained normocalcemic after single gland excision guided by intraoperative parathyroid hormone assay. Another six patients in the immediate postoperative period had normocalcemia. One patient had persistent hypercalcemia. Unilateral neck exploration was possible in 29 patients. The average operating time for initial parathyroidectomy was 50 (range 20-130) minutes. Nineteen patients were eligible for ambulatory surgery. Seven were discharged without an overnight stay, 11 had a 23-hour "social" admission, and one was kept overnight after a prolonged surgical procedure. Permanent hypoparathyroidism and laryngeal nerve injury were not observed. The mortality rate related to the procedure was 0%; there was one postoperative (do not resuscitate) death caused by colonic hemorrhage. With an average follow-up of 2 years, 64% of the patients had marked improvement of symptoms. CONCLUSION: Adjunctive use of preoperative localization and intraoperative parathyroid hormone assay has made "limited" parathyroidectomy a safe, effective treatment option in geriatric patients with primary hyperparathyroidism.

Late parathyroid function after successful parathyroidectomy guided by intraoperative hormone assay (QPTH) compared with the standard bilateral neck exploration.

BACKGROUND: Controversy continues between bilateral neck exploration and limited parathyroidectomy. One approach depends on gland size and histopathologic factors; the other approach limits excision to only hypersecreting glands. Both have excellent early operative success, but late recurrence rates with limited exploration are unknown. METHODS: Three hundred twenty consecutive patients with primary hyperparathyroidism were followed 6 to 313 months after successful parathyroidectomy. One hundred seventy-six patients had bilateral neck exploration with excision of enlarged glands (group I); 144 patients had glands excised based on hyper-secretion (group II). Calcium and intact parathyroid hormone (iPTH) levels were measured yearly. Parathyroid gland hypersecretion was determined by elevated iPTH levels. RESULTS: In group I, 1 gland was excised in 160 patients (91%); 19 of 176 patients (11%) had elevated iPTH levels. In group II, 139 patients (97%) had 1 gland excised; 19 of 144 patients (13%) had high iPTH levels. The number of patients with more than 1 gland excised in group I (9%) is 3 times higher than in group II (3%) (P <.05). There was no significant difference in the incidence of recurrent hyperfunctioning glands between the 2 different operative approaches (chi-squared test). CONCLUSIONS: Late parathyroid gland function was comparable with both approaches. Multiple gland excision based on size alone may lead to excision of normal functioning glands.

The evolution of parathyroidectomy failures.

BACKGROUND: Reported operative failure rates for primary hyperparathyroidism range from 5% to 10%. Failure has been due to multiglandular disease, ectopic parathyroid glands, errors in frozen section, and missed diagnoses. Recently, our operative approach has changed from bilateral cervical exploration to direction by preoperative localization and intraoperative quick parathyroid hormone assay. The purpose of this study is to examine the causes and rates of failure in this evolving approach to parathyroidectomy. METHODS: Among 447 consecutive cases of primary hyperparathyroidectomy, 20 operative failures were examined. Three different operative approaches were compared with respect to causes and rates of failure. RESULTS: From 1969 to 1989, with bilateral neck exploration, failure was due to missed diagnoses, ectopic glands, multiglandular disease, and unknown causes, with a failure rate of 5%. From 1990 to 1993, with bilateral neck exploration and quick parathyroid hormone assay, failure was due to ectopic mediastinal glands, misinterpretation of frozen section, and operative judgment, with a failure rate of 10%. From 1993 to 1998, with preoperative localization and quick parathyroid hormone assay, the two operative failures (1.5%) were due to operative judgment and misinterpretation of the quick parathyroid hormone assay. CONCLUSIONS: The new surgical approach combining preoperative localization studies and intraoperative parathyroid hormone monitoring has eliminated the most common causes of parathyroidectomy failure and has significantly decreased the operative failure rate.

Parathyroidectomy: new criteria for evaluating outcome.

Following successful parathyroidectomy, subjective improvement in recognized symptoms and in the overall "well being" of asymptomatic primary hyperparathyroid patients has been well documented. Because quantitative methods for measuring parathyroid hormone (PTH) and normal reference ranges of serum calcium have changed in recent years, a revised biochemical criteria for evaluating postoperative outcome has become necessary. Two hundred seventy-one selected patients were followed for an average of 6.3 years after parathyroidectomy. Although 257 patients had serum calcium levels <10.6 mg/dL during the entire follow-up period, 15 per cent of them had elevated intact PTH (iPTH) levels. Fourteen patients had calcium levels > or =10.6 mg/dL at some point during follow-up, with nine patients (64%) showing high iPTH levels and eight (57%) of them developing recurrent hyperparathyroidism (calcium > or =11 mg/dL and iPTH > or =68 pg/mL). Of the 14 remaining patients, 5 had hypercalcemia with normal iPTH levels. In patients with successfully treated primary hyperparathyroidism, the recommended annual follow-up is: 1) monitor total serum calcium only if serum calcium level is <10.6 mg/dL, or if serum calcium level is > or =10.6 mg/dL; and 2) monitor serum calcium and PTH levels, because these patients have an increased incidence of hyperfunctioning parathyroid glands, which may point to late recurrence.

Improved success rate in reoperative parathyroidectomy with intraoperative PTH assay.

OBJECTIVE: The clinical usefulness of preoperative localization and intraoperative PTH assay (QPTH) in primary hyperparathyroidism have been established. However, without the use of QPTH, the parathyroidectomy failure rate remains 5% to 10% in large reported series and is probably much higher in the hands of less experienced parathyroid surgeons. Persistent hypercalcemia requires another surgical procedure. The authors compared the outcomes in 50 consecutive patients undergoing more difficult secondary parathyroidectomy with and without the adjunctive support of QPTH. METHODS: Two groups of similar patients underwent reoperative parathyroidectomy for failed surgery or recurrent disease. The successful return to normocalcemia in group I, with QPTH used to localize and confirm complete excision of all hyperfunctioning glands, was compared with group II, who did not have this intraoperative adjunct. RESULTS: In 31/33 patients in group I, calcium levels returned to normal. With good preoperative localization studies, 17 patients underwent successful straightforward parathyroidectomies as predicted by QPTH. In the other 14 patients, QPTH assay proved extremely beneficial by facilitating localization with differential venous sampling; measuring the increase in hormone secretion after massage of specific areas; recognizing suspicious nonparathyroid tissue excised without a decrease in hormone levels, avoiding frozen-section delay; and correctly identifying the excision of abnormal tissue despite false-positive/false-negative sestamibi scans. In group II, who underwent surgery before QPTH was available, 4 of 17 patients (24%) remained hypercalcemic after extensive reexploration. CONCLUSION: With the intraoperative hormone assay used to facilitate localization and confirm excision of all hyperfunctioning tissue, the success rate of reoperative parathyroidectomy has improved from 76% to 94%.

The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program.

OBJECTIVE: To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans. SUMMARY BACKGROUND DATA: Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive. METHODS: This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA). RESULTS: The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. CONCLUSIONS: Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.

Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality rates for surgical services in Veterans Health Administration. STUDY DESIGN: This cohort study was conducted in 44 Veterans Affairs Medical Centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measure was all-cause mortality within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. Risk-adjusted surgical mortality rates were expressed as observed-to-expected ratios and were compared with unadjusted 30-day postoperative mortality rates. RESULTS: Patient risk factors predictive of postoperative mortality included serum albumin level, American Society of Anesthesia class, emergency operation, and 31 additional preoperative variables. Considerable variability in unadjusted mortality rates for all operations was observed across the 44 hospitals (1.2-5.4%). After risk adjustment, observed-to-expected ratios ranged from 0.49 to 1.53. Rank order correlation of the hospitals by unadjusted and risk-adjusted mortality rates for all operations was 0.64. Ninety-three percent of the hospitals changed rank after risk adjustment, 50% by more than 5 and 25% by more than 10. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of risk-adjusted postoperative mortality rates after major noncardiac operations. Risk adjustment had an appreciable impact on the rank ordering of the hospitals and provided a means for monitoring and potentially improving the quality of surgical care.

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.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality and morbidity rates for surgical services in the Veterans Health Administration. STUDY DESIGN: This was a cohort study conducted at 44 Veterans Affairs Medical Centers closely affiliated with university medical centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measures in this report are 21 postoperative adverse events (morbidities) occurring within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. RESULTS: Patient risk factors predictive of postoperative morbidity included serum albumin level, American Society of Anesthesia class, the complexity of the operation, and 17 other preoperative risk variables. Wide variation in the unadjusted rates of one or more postoperative morbidities for all operations was observed across the 44 hospitals (7.4-28.4%). Risk-adjusted observed-to-expected ratios ranged from 0.49 to 1.46. The Spearman rank order correlation between the ranking of the hospitals based on unadjusted morbidity rates and risk-adjusted observed-to-expected ratios for all operations was 0.87. There was little or no correlation between the rank order of the hospitals by risk-adjusted morbidity and risk-adjusted mortality. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of postoperative mortality and morbidity rates after major noncardiac operations. Risk adjustment had only a modest effect on the rank order of the hospitals.

Incidence of multiglandular disease in primary hyperparathyroidism determined by parathyroid hormone secretion.

BACKGROUND: Successful parathyroidectomy depends on recognition and excision of all hyperfunctioning parathyroid glands. Because histologic definition is limited, multiglandular disease (MGD) is usually determined grossly by means of estimation of gland size and the experience of the surgeon, resulting in frequency varying from 8% to 33%. Normalization of elevated intraoperative intact parathyroid hormone (iPTH) levels after excision of all hyperfunctioning glands is necessary for postoperative normocalcemia and indicates normal secretion of remaining parathyroids. Abnormal hormone secretion measured during operation has been used to define the extent of excision and the incidence of MGD. METHODS: One hundred ten consecutive parathyroidectomy patients with no previous neck surgery or history of multiple endocrine neoplasia had intraoperative iPTH assays performed before and after excision of any suspected abnormal parathyroid gland(s). A drop in iPTH level after gland excision predicted postoperative normal calcium levels. RESULTS: All patients except one had normalization of serum calcium levels (average follow-up, 15 months). One hundred five patients had only one hyperfunctioning gland removed, and all have remained normocalcemic. Five (5%) patients had more than one gland involved: four had two or more hyperfunctioning parathyroids and one patient, who had a large parathyroid cyst removed, remained hypercalcemic. CONCLUSIONS: By using a biochemical assay, instead of estimated size, to predict which parathyroid glands are hypersecreting, the incidence of MGD in primary hyperparathyroidism was found to be 5%.

Intraoperative parathyroid hormone monitoring as an adjunct to parathyroidectomy.

BACKGROUND: Parathyroidectomy has a success rate of greater than 95% in the hands of experienced surgeons. To maintain this result in a more cost-effective way, intraoperative monitoring of intact parathyroid hormone (iPTH) has been used to decrease operative times. This technique signals when all hyperfunctioning tissue has been excised or when further dissection is necessary. METHODS: Eighty-nine consecutive patients with hyperparathyroidism had plasma samples measured for iPTH levels during parathyroidectomy. Nine patients had previous neck explorations. Perioperative iPTH measurements using immunochemiluminescent assays with a turnaround time of 10 minutes were done after excision of each suspected abnormal parathyroid gland. RESULTS: All patients except one returned to and maintained normal calcium levels during the follow-up period of 8 months (range, 1 to 25 months). Prediction of postoperative calcium levels by means of quick immunochemiluminescent assay has a sensitivity of 97%, specificity of 100%, and an overall accuracy of 97%. Specific influence on surgical judgment was noted in four patients with multiglandular disease, in seven with difficult localization problems, and in one patient in whom the hyperfunctioning parathyroid tissue was not recognized. Monitoring the plasma iPTH levels during parathyroidectomy directly aided the surgeon's operative approach in these 12 patients. CONCLUSIONS: Intraoperative iPTH assay is useful with predictive accuracy of 97%. It influenced or changed the operative approach in 13% of patients.

Ambulatory parathyroidectomy for primary hyperparathyroidism.

OBJECTIVE: To evaluate whether the combined application of preoperative localization and intraoperative monitoring of intact parathyroid hormone (iPTH) levels could facilitate safe outpatient parathyroidectomy. DESIGN: Consecutive patients, who had no antecedent social or medical conditions mandating hospitalization, were prospectively offered ambulatory parathyroidectomy with a mean follow-up of 7 months (range, 1-25 months). SETTING: Tertiary care referral center PATIENTS: From 85 patients who had primary hyperparathyroidism with hypercalcemia and elevated iPTH levels, 57 were offered outpatient parathyroidectomy. Nineteen patients were asymptomatic, 3 had hypercalcemic crisis, and the others gave a history of renal stones or had complaints consistent with bone disease. INTERVENTIONS: Technetium Tc 99m sestamibi scintiscans were used for preoperative localization. Monitoring iPTH levels during parathyroidectomy quantitatively assured the surgeon (G.L.I. only) when all hyperfunctioning glands were excised. MAIN OUTCOME MEASURE: The number of patients without complications and with short operative times who were discharged without hospital admission or overnight stay. RESULTS: The combination of preoperative localization of abnormal parathyroid glands and a decline in circulating iPTH levels predicting postoperative normocalcemia after excision of all hyperfunctioning glands resulted in successful parathyroidectomy in 84 of 85 patients. A decreased operative time (average, 52 minutes) with minimal neck dissection permitted outpatient parathyroidectomy in 42 of 57 eligible patients. CONCLUSIONS: The combination of preoperative parathyroid scintiscan localization and iPTH level monitoring during surgery permitted successful parathyroidectomy in an ambulatory setting in half of a consecutive series of patients with primary hyperparathyroidism. The safety, success, and likely cost savings of this approach suggest wider application.

Efficient parathyroidectomy guided by SPECT-MIBI and hormonal measurements.

UNLABELLED: Parathyroidectomy is a difficult and lengthy operation which is noncurative in 6% to 10% of cases. To improve the efficiency of this operation, a new dual diagnostic approach was prospectively applied. METHODS: Preoperative tomographic 99mTc-sestamibi (MIBI) scintography and intraoperative measurements of circulating parathyroid hormone (PTH) levels by a quick assay (QPTH) were used. Scintigraphy comprised immediate and delayed planar and SPECT of the neck and chest, following 20 mCi MIBI. The presence and location of persistent foci of abnormal activity found within the neck mediastinum on volume-rendered reprojection (RPJ) of the SPECT data were reported. The surgion, guided by the three-dimensional MIBI-SPECT/RPJ images, identified and excised the single or most prominent scintigraphic focus and applied the QPTH. If PTH levels fell from baseline by at least 50%, the operation was concluded. RESULTS: The operative time of primary parathyroidectomy was reduced from an average of 90 min (before the introduction of scintigraphy and intraoperative PTH measurements) to 57 min. All but two patients became normocalcemic. In 58 consecutive patients with hyperparathyroidism, MIBI-SPECT/RPJ correctly and precisely identified 51 of 53 (96%) primary parathyroid adenomas, 14 to 15 secondary hyperplasias and 2 of 3 hyperplastic glands in MEN (sensitivity 94%, specificity 92%). QPTH verified the excision of the primary parathyroid adenomas and predicted normocalcemia in 50 of 52 patients. In 6 patients with misleading scintigraphy, QPTH was especially useful and guided the surgeon to continue the operation until the abnormal parathyroid tissue was found and excised. CONCLUSION: MIBI-SPEC/RPJ and QPTH sequentially applied improved the efficiency of parathyroidectomy.

The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care.

BACKGROUND: The use of surgical outcome in the comparative assessment of the quality of surgical care is predicted on the development of proper models that adjust for the severity of the preoperative risk factors of the patient. The National Veterans Administration Surgical Risk Study was designed to collect reliable, valid data about patient risk and outcome for major surgery in the Veterans Health Administration (VHA) and to report comparative risk-adjusted surgical morbidity and mortality rates for surgical services in VHA. This study describes the rationale and methods used in the Risk Study and reports on the frequency distribution of the data elements that will be used in the development of risk-adjusted reporting of surgical outcome. STUDY DESIGN: This study was a prospective observational study in which dedicated nurses collected preoperative, intraoperative, and outcome data on patients undergoing noncardiac operations using general, spinal, and epidural anesthesia in 44 Veterans Administration Medical Centers. Outcome measures included all cause mortality within the 30 days after the index procedure and 21 major morbidities. RESULTS: Eighty-three thousand nine hundred fifty-eight cases meeting inclusion criteria were entered in the study between October 1, 1991 and December 31, 1993. Ninety-seven percent of patients were men, with a mean age of 60.1 +/- 13.6 (standard deviation) years. The most common preoperative risk factors were smoking (40.7 percent) and hypertension (36.1 percent). Of the patients, 84.6 percent had one or more risk factors. The most common procedures were transurethral resection of the prostate gland (6.7 percent), total knee replacement (3.1 percent), thromboendarterectomy (2.4 percent), partial colectomy (2.2 percent), and total hip replacement (2 percent). The unadjusted mortality rate was 3.1 percent at 30 days. The most common postoperative morbidities were pneumonia (3.6 percent), urinary tract infection (3.5 percent), and failure to wean from the ventilator at 48 hours postoperatively (3.2 percent). Seventeen percent of the patients have one or more major complications. CONCLUSIONS: The Veterans Health Administration has successfully implemented an outcome reporting system for major surgery that prospectively collects patient risk and outcome information reliably and validly. Risk adjustment models and comparative hospital-specific rates of risk-adjusted outcomes are currently being developed.