Health Report:

Surgery, NSQIP, Complications & Death


"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS

Photo of Dr. Wascher

Last Updated:  10/04/2009

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.





As a practicing cancer surgeon, complications following surgery (including death, which can be considered the “ultimate” complication of surgery) are of great concern to me.  As federal and state government officials continue to grapple with the tremendously complex and seemingly insoluble deficiencies in our current health care system here in the United States, one area that has been receiving increased attention, lately, has been patient outcomes following surgery. 


Traditionally, surgeons have reviewed and analyzed their complications during regular morbidity and mortality (“M&M”) conferences.  Each surgical complication is presented by the operating surgeon during such conferences, and the surgeon, and his or her peers, then analyze the patient’s clinical course.  A consensus is then, hopefully, reached as to the proximate causes of the patient’s complications.  Therefore, the goal of M&M conferences is to retrospectively identify patient risk factors for complications, as well as to examine the quality of care that patients have received, in an effort to identify areas where patient care can potentially be improved, and complications, perhaps, prevented. 


Unfortunately, there are several obvious weaknesses associated with this approach to quality improvement in patient care.  The first and perhaps greatest weakness of M&M conferences is their retrospective nature.  A great deal of subjectivity is injected into the analysis of specific patient care factors when the operating surgeon reviews his or her own patient complications, in hindsight, and then presents selected patients to other surgeons participating in the M&M conference.  Whether by accident or by intention, important lapses in diagnosis and/or treatment are commonly withheld during such conferences, which often leads to an incomplete picture of the events leading up to patient complications and deaths. 


Another pitfall of M&M conferences is directly related to the interpersonal and professional dynamics between surgeons participating in such conferences.  Some medical centers’ M&M conferences have a justly earned reputation for being ruthlessly aggressive in holding individual surgeons accountable for their complications, in an effort to improve the quality of patient care.  At the same time, in many other medical centers, M&M conferences are relatively benign and quasi-social affairs among collegial groups of surgeons, and a critical evaluation of surgeons’ care of their patients is, instead, substituted with an affable and superficial review of patient complications and deaths that, too often, fails to drill down to specific potential patient care deficiencies.  Both extremes in approaches to surgeon morbidity and mortality conferences tend to obscure the true causes and events associated with patient complications and unexpected deaths following surgery, due to the many biases that are injected into purely retrospective M&M conferences. 


In an attempt to overcome the intrinsic biases and limitations associated with a purely retrospective assessment of surgical complications, most surgeons at morbidity and mortality conferences present clinical research studies, published in peer-reviewed medical journals, in an effort to inject some scientific objectivity into the discussion.  However, once again, personal biases still often arise despite attempts to present published clinical data relevant to the complication being discussed, as it is almost always possible to find a couple of published papers that appear to support the decisions that were made by the operating surgeon.



In response to growing concerns regarding the quality of surgical care at Veterans Administration hospitals in the United States, a paradigm-shifting approach to the analysis of surgical complications was initiated by the Veterans Administration (VA) in 1991.  Out of an abundance of concern over the high rate of postoperative complications and deaths at several VA medical centers, the National Surgical Quality Improvement Program (NSQIP) was born.  Between 1991 and 2001, VA medical centers prospectively collected data encompassing multiple patient risk factors, as well as data related to 30-day postoperative morbidity (complications) rates, and 30-day postoperative mortality (death) rates.  Using this prospectively collected data to improve surgical care at all of the VA’s 132 medical centers that perform surgery, the VA was able to subsequently demonstrate some striking improvements in patient outcomes.  Specifically, between 1991 and 2001, 30-day death rates following surgery decreased by 27 percent, while postoperative complications occurring within 30 days of surgery were decreased by a whopping 45 percent.  The average length of stay after surgery also declined by a rather incredible 50 percent (from an average of 9 days, to 4 days).  Needless to say, if the NSQIP results from these 132 VA hospitals were to be universally replicated in all of the nearly 6,000 hospitals in the United States, the potential for improvement in patient morbidity and mortality, and consequently in the cost of delivering high quality surgical care in the United States, would be enormous (currently, only 243 civilian hospitals are listed as voluntary NSQIP participants by the program’s steward, the American College of Surgeons).


As surgeons finally begin to move from their long tradition of well-intentioned but seriously flawed retrospective analysis of postoperative complications, and into the dawning era of prospective data collection and analysis, a detailed evaluation of the data from programs such as NSQIP will continue to yield important new insights into the causes of preventable surgical complications and deaths.  Indeed, a newly published study in the prestigious New England Journal of Medicine, from the University of Michigan, evaluated NSQIP data collected on 84,730 surgical patients between 2005 and 2007.  Unlike most prior studies that have used NSQIP data to assess the potential causes of preventable surgical complications and mortality, the authors of this research study were particularly interested in the role of patient management in preventing postoperative deaths once complications had, in fact, already occurred.


The authors of this important clinical study ranked the NSQIP-participating hospitals according to their overall death rates for patients undergoing inpatient surgery, and divided them into five different groups, based upon their mortality rankings.  The researchers then evaluated and compared the extensive NSQIP data in each of these five groups of hospitals.  The results of this analysis were both intriguing and, seemingly, rather counterintuitive.


The first important finding of this study was that the actual incidence of complications following surgery did not significantly vary among the hospitals studied.  The second illuminating finding of this study is that, unlike complication rates, death rates following surgery did significantly vary among these same hospitals (from 3.5 percent among the best performing hospitals, to 6.9 percent among the poorest performing hospitals). 


A comprehensive review of the NSQIP data for these nearly 85,000 surgical patients confirmed that the two-fold difference in death rates that was observed between the best performing and worst performing hospitals appeared to be directly related to the way that patients with major complications were managed once the complications occurred, and not due to any underlying difference in the actual incidence of complications among the various hospitals.  Thus, the authors concluded that our attention must not only continue to focus on preventing complications, but that we should also more aggressively concentrate on our actual management of complications following surgery, once they occur, in our ongoing efforts to reduce the incidence of preventable postoperative deaths.


In view of the landmark Veterans Administration NSQIP findings linking the prevention of complications with a decrease in postoperative death rates, it may seem counterintuitive that the two-fold difference in postoperative death rates observed in this new study appeared to be unrelated to the actual incidence of complications among the hospitals studied.  However, it is important to remember that these same hospitals had already previously demonstrated their strong commitment to reducing preventable postoperative complications through their voluntary participation in the NSQIP program.  Therefore, the finding of this study that complication rates did not vary considerably among these particular hospitals may not be applicable to the vast majority of hospitals that have not yet adopted NSQIP guidelines (or other comparable, prospective surgical quality improvement programs).


The results of this study clearly show that, while the implementation of the NSQIP program is helping participating hospitals to make significant progress in reducing the incidence of complications following surgery, we still have much work to do in devising and implementing evidence-based clinical pathways for managing those complications that, despite our best efforts, still continue to occur.  Based upon the results of this important clinical research study, it appears that  we can further and dramatically reduce the incidence of unnecessary deaths following surgery while, at the same time, significantly reducing the already excessive cost of delivering quality health care in the United States.  


Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity


Dr. Wascher is an oncologic surgeon, a professor of surgery, a widely published author, and the Physician-in-Chief for Surgical Oncology at the Kaiser Permanente healthcare system in Orange County, California



"A Cancer Prevention Guide for the Human Race"

(Anticipated Publication Date:  March 2010)

Link to TV36 Interview with Dr. Wascher

(Click above image for TV36 interview of Dr. Wascher)

Bookmark and Share

Send your feedback to Dr. Wascher at:



Links to Other Health & Wellness Sites

Copyright 2007 - 2009  

Robert A. Wascher, MD, FACS  

All rights reserved

Dr. Wascher's Archives:

9-27-2009:  Stress, Heart Disease, Exercise & Death

9-20-2009:  Vitamin D & Colorectal Cancer Survival

9-13-2009:  H1N1 Swine Flu Update

9-7-2009:   Green Tea, Aging & Lifespan    

8-30-2009:  Irritable Bowel Syndrome (IBS), Diet & Fiber 

8-23-2009:  Update on Prostate Cancer and Cryotherapy

8-16-2009:  Exercise Improves Lymphedema Symptoms in Breast Cancer Survivors

8-9-2009:   Breast Cancer Recurrence, Death & Vitamin D

8-2-2009:   Honesty, Dishonesty & Brain Function

7-26-2009:  Coronary Artery CT Scans & Cancer Risk

7-19-2009:  Hormone Replacement Therapy (HRT) & Ovarian Cancer

7-12-2009:  Cancer & Metformin (Glucophage)

7-5-2009:    Prostate Cancer & Green Tea

6-28-2009:  Air Pollution & the Risk of Deep Venous Thrombosis (DVT)

6-21-2009:  Red Yeast Rice, Statins & Cholesterol

6-14-2009:  Bone Marrow Stem Cell Transplant & Congestive Heart Failure (CHF)

6-7-2009:    Diet, Soy & Breast Cancer Risk

5-31-2009:  Diet and Prostate Cancer Risk

5-24-2009:   Diabetes, Glucose Control & Death

5-17-2009:  Drug Company Marketing & Physician Prescribing Bias

5-10-2009:   Hemorrhoids & Surgery

5-3-2009:    Statin Drugs & Blood Clots (Thromboembolism)

4-26-2009:   Are We Really Losing the War on Cancer?

4-19-2009:  Exercise in Middle Age & Risk of Death

4-12-2009:   Can Chronic Stress Harm Your Heart?

4-5-2009:    Does PSA Testing for Prostate Cancer Save Lives?

3-22-2009:  CABG Surgery vs. PCI in Diabetics with Coronary Artery Disease; Sweetened Beverages and Coronary Artery Disease

3-15-2009:   Depression, Stress, Anger & Heart Disease

3-8-2009:   Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children

3-1-2009:    Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children

2-22-2009:   Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer

2-15-2009:  Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones 

2-8-2009:   Hormone Replacement Therapy (HRT) & Breast Cancer; Stool DNA Testing & Cancer of the Colon & Rectum

2-1-2009:   Obesity and the Complications of Diverticulosis (Diverticulitis & Bleeding); Obesity, Weight Loss & Urinary Incontinence 

1-25-2009:  Prostate Cancer, Fatigue & Exercise; Does your Surgeon “Warm-up” Before Surgery?

1-18-2009:  Cancer & Vitamins; Teenagers, MySpace and Risky Behaviors

1-11-2009:  Exercise Reverses Some Effects of Fatty Meals; Vitamin C and Blood Pressure

1-4-2009:    Secondhand Smoke & Heart Attack Risk; Poor Physical Fitness During Childhood & Heart Disease Risk During Adulthood

12-28-2008:  Stress & Your Risk of Heart Attack; Vitamin D & the Prevention of Colon & Rectal Polyps

12-21-2008:  Breast Cancer Incidence & Hormone Replacement Therapy; Circumcision & the Risk of HPV & HIV Infection

12-14-2008:  Vitamin E, Vitamin C and Selenium Do Not Prevent Cancer;  Postscript: A Possible Cure for Down’s Syndrome

12-7-2008:    Generic vs. Brand-Name Drugs; Stress & Breast Cancer Survival

11-30-2008:   A Possible Cure for Down’s Syndrome?; Smoking & Cognitive Decline; Calcium & Vitamin D & Breast Cancer Risk

11-23-2008:  Breast Cancer & Fish Oil; Lymphedema after Breast Cancer Treatment; Vasectomy & Prostate Cancer Risk

11-16-2008:  Vitamin E & Vitamin C: No Impact on Cardiovascular Disease Risk; Does Lack of Sleep Increase Stroke & Heart Attack Risk in Hypertensive Patients?

11-9-2008:   Statins Cut Heart Attack Risk Even with Normal Cholesterol Levels; Statins & PSA Level

11-2-2008:   Radiation Treatment of Prostate Cancer & Second Cancers; Sexual Content on TV & Teen Pregnancy Risk

10-26-2008:  Smoking & Quality of Life

10-19-2008:  Agent Orange & Prostate Cancer

10-12-2008:  Pomegranate Juice & Prostate Cancer

10-5-2008:   Central Obesity & Dementia; Diet, Vitamin D, Calcium, & Colon Cancer

9-28-2008:   Publication & Citation Bias in Favor of Industry-Funded Research?

9-21-2008:   Does TylenolŪ (Acetaminophen) Cause Asthma?

9-14-2008:   Arthroscopic Knee Surgery- No Better than Placebo?; A Healthy Lifestyle Prevents Stroke

8-23-2008:   Alcohol Abuse Before & After Military Deployment; Running & Age; Running & Your Testicles

8-12-2008:   Green Tea & Diabetes; Breastfeeding & Adult Cholesterol Levels; Fish Oil & Senile Macular Degeneration

8-3-2008:    Exercise & Weight Loss; Green Tea, Folic Acid & Breast Cancer Risk; Foreign Language Interpreters & ICU Patients

7-26-2008:   Viagra & Sexual Function in Women; Patient-Reported Adverse Hospital Events; Curcumin & Pancreatic Cancer

7-13-2008:   Erectile Dysfunction & Frequency of Sex; Muscle Strength & Mortality in Men; Cryoablation for Prostate Cancer

7-6-2008:    Sleep, Melatonin & Breast Cancer Risk; Mediterranean Diet & Cancer Risk; New Treatment for Varicose Veins

6-29-2008:   Bone Marrow Stem Cells & Liver Failure; Vitamin D & Colorectal Cancer Survival; Green Tea & Colorectal Cancer

6-22-2008:   Obesity, Lifestyle & Heart Disease; Effects of Lifestyle & Nutrition on Prostate Cancer; Ginkgo Biloba, Ulcerative Colitis & Colorectal Cancer

6-15-2008:   Preventable Deaths after Coronary Artery Bypass Graft (CABG) Surgery; Green Tea & Colorectal Cancer; Attention-Deficit/Hyperactivity Disorder (ADHD) & St. John’s Wort

6-8-2008:   Vitamin D & Prostate Cancer Risk; Radiofrequency Ablation (RFA) of Kidney (Renal) Cancer; Antisense Telomerase & Cancer

6-2-2008:   Acute Coronary Syndrome- Do You Know the Symptoms?; Green Tea & Lung Cancer; Episiotomy & Subsequent Deliveries- An Unkind Cut

5-25-2008:  Early Childhood Screening Predicts Later Behavioral Problems; Psychiatric Disorders Among Parents of Autistic Children; Social & Psychiatric Profiles of Young Adults Born Prematurely

5-18-2008:  Can Statins Reverse Coronary Artery Disease?; Does Breast Ultrasound Improve Breast Cancer Detection?; Preventive Care Services at Veterans Administration (VA) Medical Centers

5-11-2008:  Smoking Cessation & Risk of Death; Childhood Traumas & Adult Suicide Risk; “White Coat Hypertension” & Risk of Cardiovascular Disease

5-4-2008:  Super-Size Me: Fast Food’s Effects on Your Liver; Exercise, Weight & Coronary Artery Disease; Contamination of Surgical Instruments in the Operating Room

4-27-2008:  Stents vs. Bypass Surgery for Coronary Artery Disease; The “DASH” Hypertension Diet & Cardiovascular Disease Prevention; Testosterone Therapy for Women with Decreased Sexual Desire & Function

4-20-2008:  BRCA Breast Cancer Mutations & MRI Scans; Bladder Cancer Prevention with Broccoli?; Diabetes: Risk of Death Due to Heart Attack & Stroke

4-13-2008:  Breast Cancer Recurrence & Hormone Replacement Therapy (HRT); Carotid Artery Disease: Surgery vs. Stents?; Statin Drugs & Cancer Prevention

4-6-2008:  Human Papilloma Virus (HPV), Pap Smear Results & Cervical Cancer; Human Papilloma Virus (HPV) Infection & Oral Cancer; Hormone Replacement Therapy (HRT) & the Risk of Gastroesophageal Reflux Disorder (GERD)

3-30-2008:  Abdominal Obesity & the Risk of Death in Women; Folic Acid Pretreatment & Heart Attacks; Pancreatic Cancer Regression after Injections of Bacteria

3-23-2008:  Age of Transfused Blood & Risk of Complications after Surgery; Obesity, Blood Pressure & Heart Size in Children

3-16-2008:  Benefits of a Full Drug Coverage Plan for Medicare Patients?; Parent-Teen Conversations about Sex; Soy (Genistein) & Prostate Cancer

3-9-2008:  Flat Colorectal Adenomas & Cancer; Health Risks after Stopping Hormone Replacement Therapy (HRT); Television, Children & Obesity 

3-2-2008:  Medication & Risk of Death After Heart Attack; Hormone Replacement Therapy (HRT) & Mammogram Results; Selenium: Cancer, Heart Disease & Death

2-23-2008:  Universal Healthcare Insurance Study; Glucosamine & Arthritis

2-17-2008:  Exceptional Longevity in Men; Testosterone & Risk of Prostate Cancer; Smoking & Pre-malignant Colorectal Polyps

2-10-2008:  Thrombus Aspiration from Coronary Arteries; Intensive Management of Diabetes & Death; Possible Cure for  Down's Syndrome?

2-3-2008:   Vitamin D & Cardiovascular Health; Vitamin D & Breast Cancer; Green Tea & Colorectal Cancer

1-27-2008:  Colorectal Cancer, Esophageal Cancer & Pancreatic Cancer: Update from the 2008 American Society of Clinical Oncology's Gastrointestinal Cancers Symposium

1-20-2008:  Testosterone Levels & Risk of Fractures in Elderly Men; Air Pollution & DNA Damage in Sperm; Statins & Trauma Survival in the Elderly

1-12-2008:  Statins, Diabetes & Stroke and Obesity; GERD & Esophageal Cancer

1-7-2008:   Testosterone Supplements in Elderly Men; Colorectal Cancer-- Reasons for Poor Compliance with Screening Recommendations

12-31-2007: Minority Women, Hormone Replacement Therapy & Breast Cancer; Does Health Insurance Improve Health?

12-23-2007:  Is Coffee Safe After a Heart Attack?; Impact of Divorce on the Environment; Hypertension & the Risk of Dementia; Emotional Vitality & the Risk of Heart Disease

12-16-2007:   Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality 

12-11-2007:  Bias in Medical Research; Carbon Nanotubes & Radiofrequency: A New Weapon Against Cancer?; Childhood Obesity & Risk of Adult Heart Disease

12-2-2007:  Obesity & Risk of Cancer; Testosterone Level & Risk of Death; Drug Company Funding of Research & Results; Smoking & the Risk of Colon & Rectal Cancer 


Top of Page