Objective: To determine if composite measures based on process indicators are consistent with short-term outcome indicators in surgical colorectal cancer care. Design: Longitudinal analysis of consistency between composite measures based on process indicators and outcome indicators for 85 Dutch hospitals. Setting: The Dutch Surgical Colorectal Audit database, the Netherlands. Participants: 4732 elective patients with colon carcinoma and 2239 with rectum carcinoma treated in 85 hospitals were included in the analyses. Main outcome measures: All available process indicators were aggregated into five different composite measures. The association of the different composite measures with risk-adjusted postoperative mortality and morbidity was analysed at the patient and hospital level. Results: At the patient level, only one of the composite measures was negatively associated with morbidity for rectum carcinoma. At the hospital level, a strong negative association was found between composite measures and hospital mortality and morbidity rates for rectum carcinoma (p<0.05), and hospital morbidity rates for colon carcinoma. Conclusions: For individual patients, a high score on the composite measures based on process indicators is not associated with better short-term outcome. However, at the hospital level, a good score on the composite measures based on process indicators was consistent with more favourable risk-adjusted short-term outcome rates.

Aims: The purpose of this study was to determine how expected mortality based on case-mix varies between colorectal cancer patients treated in non-teaching, teaching and university hospitals, or high, intermediate and low-volume hospitals in the Netherlands. Material and methods: We used the database of the Dutch Surgical Colorectal Audit 2010. Factors predicting mortality after colon and rectum carcinoma resections were identified using logistic regression models. Using these models, expected mortality was calculated for each patient. Results: 8580 patients treated in 90 hospitals were included in the analysis. For colon carcinoma, hospitals' expected mortality ranged from 1.5 to 14%. Average expected mortality was lower in patients treated in high-volume hospitals than in low-volume hospitals (5.0 vs. 4.3%, p < 0.05). For rectum carcinoma, hospitals expected mortality varied from 0.5 to 7.5%. Average expected mortality was higher in patients treated in non-teaching and teaching hospitals than in university hospitals (2.7 and 2.3 vs. 1.3%, p < 0.01). Furthermore, rectum carcinoma patients treated in high-volume hospitals had a higher expected mortality than patients treated in low-volume hospitals (2.6 vs. 2.2% p < 0.05). We found no differences in risk-adjusted mortality. Conclusions: High-risk patients are not evenly distributed between hospitals. Using the expected mortality as an integrated measure for case-mix can help to gain insight in where high-risk patients go. The large variation in expected mortality between individual hospitals, hospital types and volume groups underlines the need for risk-adjustment when comparing hospital performances.