Validated index scores severity of postsurgical morbidity

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1. The Comprehensive Complications Index (CCI) assigns a score assessing severity of one or multiple combined postoperative complications. This index can be used as a universal morbidity endpoint for research studies and quality improvement initiatives.

2. CCI combines both patient and surgeon grading of complication severity, and has been validated using multiple methods and patient populations.

Evidence Rating Level: 2 (Good)

Study Rundown: Standardized reporting of post-surgical morbidity in the literature has been a long-standing issue. Authors of this study previously created the Clavien-Dindo classification, which divides surgical complications into four broad categories based on severity. It ranges from Grade I (any deviation from normal postoperative course without need for pharmacologic or other intervention) to Grade V (death). This paper proposes a Comprehensive Complications Index that assigns a 0-100 score to all postoperative complications that occurred to a particular patient, combining their number and severity. CCI can therefore be used as a comprehensive mortality endpoint for both research and quality literature. An online CCI calculator can be found at To create this index, authors surveyed a large population of preoperative patients, surgeons and physicians involved in postoperative care. Additionally, CCI was put through a rigorous validation process. For this score to be widely adopted, populations in other countries must be surveyed for their grading of each complication. Additionally, it must be validated in postoperative populations other than those undergoing elective abdominal surgery.

Click to read the study in Annals of Surgery

Click to read the accompanying editorial in Annals of Surgery

Relevant Reading: The Clavien-Dindo classification of surgical complications: five-year experience.

In Depth [outcomes cohort study]: Over 200 preoperative patients and a similar number of physicians were surveyed to grade the severity of postoperative complications and various combinations of complications. The score medians were combined and fitted to a normal distribution resulting in a 0 to 100 severity scale in a process pioneered in economics called the operation risk index. The resulting score or the Comprehensive Complications Index (CCI) was validated in four ways using multiple postoperative patient populations in Germany. The first validation compared the previously developed Clavien-Dindo classification with CCI, confirming that the new score demonstrates superior discrimination between patients with various postoperative complications. The second validation tested CCI’s sensitivity to protective pharmacologic pre-treatment in an RCT population of liver surgery patients. CCI showed a stronger effect size than either endpoint used in the trial, namely “any complication” used as the primary outcome and “major complication alone” as the secondary. The third validation demonstrated a strong negative correlation between postoperative health status and CCI. The fourth validation utilized another economic tool, called “conjoint analysis,” which is frequently used for market research. A different set of preoperative patients was asked to complete a questionnaire grading various sets of complications on a scale of 0 to 100. Authors then compared patient-assigned grades to the computed CCI for each individual scenario, which were highly correlated (r = 0.94, p<0.001).

By Asya Ofshteyn and Allen Ho

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