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Comparison of P-POSSUM and Cr-POSSUM Scores in Patients Undergoing Colorectal Cancer Resection—Invited Critique

Comparison of P-POSSUM and Cr-POSSUM Scores in Patients Undergoing Colorectal Cancer... Assessment of outcomes for surgical services may become an important way for the government and insurance companies to grade health systems, hospitals, and individual practitioners. Any time outcomes are evaluated or compared, a method of assessing the influence of medical comorbidity on the selected outcome of a selected procedure for a selected disease must be provided to make the evaluation meaningful. POSSUM, P-POSSUM, and Cr-POSSUM scores are methods for assessing the severity of comorbid and operative factors that might influence surgical outcomes using complicated formulas associating numerous data points that include medical comorbidity and operative severity factors. Senagore and colleagues1 showed that the 3 POSSUM scores need to be calibrated by each system and suggest that comparison between 2 systems should be undertaken carefully. The Cr-POSSUM score predicts mortality closely even though missing data from the medical records of patients causes little variation in the ability to predict outcome for colon cancer. This suggests that the score for an individual patient may not be reliable. Therefore, we must be careful when using the scores to predict individual patient outcomes, influence selection of a complicated procedure, and determine futility of operative management of advanced disease on the basis of individual POSSUM scores. In the article by Horzic et al this point is emphasized by calculating the AUC. The value of 0.59 for Cr-POSSUM indicates almost random prediction of mortality for an individual patient, even though it is an accurate predictor for a population of patients with colorectal cancer. It is unlikely that the Cr-POSSUM score will ever be calculated for use in an individual patient as part of the decision making preoperative process. Several questions remain that can only be answered by more experience with the Cr-POSSUM score. What influence will surgeon judgment and experience, volume of cases, or hospital capability and resources have on the predictability of the scores? How and where does the Cr-POSSUM score interface with the definition of futility? Can Cr-POSSUM indexed outcomes reflect quality better than process improvement currently mandated by the Surgical Clinical Improvement Project programs? How will the POSSUM scores interact with the outcomes assessment in the National Surgical Quality Improvement Program project? How can we prevent health care systems, hospitals, and surgeons from “gaming” the system to improve reported outcomes on an unfair basis? Only time and more experience with these scoring systems will provide the answers to these and other questions. Correspondence: Dr Fleshman, Department of Surgery, Section of Colon and Rectal Surgery, Washington University, 660 S Euclid, Campus Box 8109, St Louis, MO 63110 (fleshmanj@wustl.edu). Financial Disclosure: None reported. References 1. Senagore AJWarmuth AJDelany CPTekkis PPFazio VW POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection [published online ahead of print July 15, 2004]. Dis Colon Rectum 2004;47 (9) 1435- 1441.10.1007/s10350-004-0604-1PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Comparison of P-POSSUM and Cr-POSSUM Scores in Patients Undergoing Colorectal Cancer Resection—Invited Critique

Archives of Surgery , Volume 142 (11) – Nov 1, 2007

Comparison of P-POSSUM and Cr-POSSUM Scores in Patients Undergoing Colorectal Cancer Resection—Invited Critique

Abstract

Assessment of outcomes for surgical services may become an important way for the government and insurance companies to grade health systems, hospitals, and individual practitioners. Any time outcomes are evaluated or compared, a method of assessing the influence of medical comorbidity on the selected outcome of a selected procedure for a selected disease must be provided to make the evaluation meaningful. POSSUM, P-POSSUM, and Cr-POSSUM scores are methods for assessing the severity of...
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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0004-0010
DOI
10.1001/archsurg.142.11.1048
Publisher site
See Article on Publisher Site

Abstract

Assessment of outcomes for surgical services may become an important way for the government and insurance companies to grade health systems, hospitals, and individual practitioners. Any time outcomes are evaluated or compared, a method of assessing the influence of medical comorbidity on the selected outcome of a selected procedure for a selected disease must be provided to make the evaluation meaningful. POSSUM, P-POSSUM, and Cr-POSSUM scores are methods for assessing the severity of comorbid and operative factors that might influence surgical outcomes using complicated formulas associating numerous data points that include medical comorbidity and operative severity factors. Senagore and colleagues1 showed that the 3 POSSUM scores need to be calibrated by each system and suggest that comparison between 2 systems should be undertaken carefully. The Cr-POSSUM score predicts mortality closely even though missing data from the medical records of patients causes little variation in the ability to predict outcome for colon cancer. This suggests that the score for an individual patient may not be reliable. Therefore, we must be careful when using the scores to predict individual patient outcomes, influence selection of a complicated procedure, and determine futility of operative management of advanced disease on the basis of individual POSSUM scores. In the article by Horzic et al this point is emphasized by calculating the AUC. The value of 0.59 for Cr-POSSUM indicates almost random prediction of mortality for an individual patient, even though it is an accurate predictor for a population of patients with colorectal cancer. It is unlikely that the Cr-POSSUM score will ever be calculated for use in an individual patient as part of the decision making preoperative process. Several questions remain that can only be answered by more experience with the Cr-POSSUM score. What influence will surgeon judgment and experience, volume of cases, or hospital capability and resources have on the predictability of the scores? How and where does the Cr-POSSUM score interface with the definition of futility? Can Cr-POSSUM indexed outcomes reflect quality better than process improvement currently mandated by the Surgical Clinical Improvement Project programs? How will the POSSUM scores interact with the outcomes assessment in the National Surgical Quality Improvement Program project? How can we prevent health care systems, hospitals, and surgeons from “gaming” the system to improve reported outcomes on an unfair basis? Only time and more experience with these scoring systems will provide the answers to these and other questions. Correspondence: Dr Fleshman, Department of Surgery, Section of Colon and Rectal Surgery, Washington University, 660 S Euclid, Campus Box 8109, St Louis, MO 63110 (fleshmanj@wustl.edu). Financial Disclosure: None reported. References 1. Senagore AJWarmuth AJDelany CPTekkis PPFazio VW POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection [published online ahead of print July 15, 2004]. Dis Colon Rectum 2004;47 (9) 1435- 1441.10.1007/s10350-004-0604-1PubMedGoogle Scholar

Journal

Archives of SurgeryAmerican Medical Association

Published: Nov 1, 2007

References