• A M van Dishoeck, M B G Koek, E W Steyerberg, B H B van Benthem, M C Vos, and H F Lingsma.
• Centre of Medical Decision Making, Department of Public Health, Erasmus MC–University Centre Rotterdam, The Netherlands. a.m.vandishoeck@erasmusmc.nl
• Br J Surg. 2013 Apr 1;100(5):628-36; discussion 637.

BackgroundComparing and ranking hospitals based on health outcomes is becoming increasingly popular, although case-mix differences between hospitals and random variation are known to distort interpretation. The aim of this study was to explore whether surgical-site infection (SSI) rates are suitable for comparing hospitals, taking into account case-mix differences and random variation.MethodsData from the national surveillance network in the Netherlands, on the eight most frequently registered types of surgery for the year 2009, were used to calculate SSI rates. The variation in SSI rate between hospitals was estimated with multivariable fixed- and random-effects logistic regression models to account for random variation and case mix. 'Rankability' (as the reliability of ranking) of the SSI rates was calculated by relating within-hospital variation to between-hospital variation.ResultsThirty-four hospitals reported on 13 629 patients, with overall SSI rates per surgical procedure varying between 0 and 15·1 per cent. Statistically significant differences in SSI rate between hospitals were found for colonic resection, caesarean section and for all operations combined. Rankability was 80 per cent for colonic resection but 0 per cent for caesarean section. Rankability was 8 per cent in all operations combined, as the differences in SSI rates were explained mainly by case mix.ConclusionWhen comparing SSI rates in all operations, differences between hospitals were explained by case mix. For individual types of surgery, case mix varied less between hospitals, and differences were explained largely by random variation. Although SSI rates may be used for monitoring quality improvement within hospitals, they should not be used for ranking hospitals.© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.

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