Supplementary Digital Content Section A Procedural codes to define study population
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1 Supplementary Digital Content Section A Procedural codes to define study population Procedure CCI codes ORTHOPEDIC Total hip replacement 1.VA.53.LA-PN ; 1.VA.53.PN-PN Total knee replacement 1.VG.53 VASCULAR Carotid endarterectomy Endovascular Abdominal aortic aneurysm repair 1.JE.57 without 1.IJ.76 on the same date (exclude concurrent CABG surgery) 1.KA.80.GQ-NRN or 1.KA.50.GS-BD or 1.KA.50.LA-BD or 1.KE.50.GQ-OA or 1.KE.51.GQ-GE [must have ICD-10 code I71.4 on the same admission] 1.KA.80.LA-XXN or Open Abdominal aortic aneurysm repair 1.KA.76.NB-XXN or 1.KA.76.MZ-XXN [must have ICD-10 code I71.4 on the same admission] Peripheral arterial bypass surgery 1.KG.76 ; 1.JM.76.MI ; 1.KT.76 ; 1.KG.80 or CCI code 1.KA.76 without ICD-10 codes I71.3 or I71.4 or I71.9 on the same admission. UROLOGIC Partial or total nephrectomy 1.PC.87 ; 1.PC.89 ; 1.PC.91
2 Total cystectomy 1.PM.89 ; 1.PM.90 ; 1.PM.91 ; 1.PM.92 INTRAPERITONEAL Large bowel and rectal surgery DAD 1.NM.87 (all except 1.NM.87.BA) or 1.NM.89 ; 1.NM.91 ; 1.NQ.89 ; 1.NQ.90 or 1.NQ.87 (all except 1.NQ.87.BA) Partial liver resection 1.OA.87 Pancreaticoduodenecto my 1.OK.87 ; 1.OK.89 ; 1.OK.91 Gastrectomy or esophagectomy 1.NF.87 ; 1.NF.89 ; 1.NF.90 ; 1.NF.91 ; 1.NF.92 ; 1.NA.88 ; 1.NA.89 ; 1.NA.90 ; 1.NA.91 ; 1.NA.92 ; 1.NA.87 THORACIC Pneumonectomy and lobectomy 1.GR.89 ; 1.GR.91 ; 1.GT.89 ; 1.GT.91 ; 1.GT.87
3 Supplementary Digital Content Section B Frailty defining diagnoses Frailty Concept Diagnoses (Examples) Malnutrition Nutritional Marasmus Other severe protein-calorie malnutrition Dementia Senile dementia with delusional or depressive features Senile dementia with delirium Impaired Vision Profound impairment, both eyes Moderate or severe impairment, better eye/lesser eye: profound Decubitus Ulcer Decubitus Ulcer Incontinence of Urine Incontinence without sensory awareness Continuous leakage Loss of Weight Abnormal loss of weight and underweight Feeding difficulties and mismanagement Incontinence of Feces Incontinence of feces Obesity (morbid) Morbid obesity Poverty Lack Of Housing Inadequate Housing Inadequate material resources Barriers to Access of Care No Med Facility For Care No Med Facilities Necessary Difficulty in Walking Difficulty in walking Abnormality of gait Fall Fall On Stairs Or Steps Fall From Wheelchair
4 Supplementary Digital Content Section C Complication codes Definition or ICD-10 type 2 diagnostic Complication Source code Postoperative mechanical ventilation OHIP G557, G405 after surgery In hospital cardiac arrest DAD Flag for heart resuscitation In hospital AKI DAD N17 In hospital MI DAD I21,I22,I20, I23.82, I24 In hospital atrial arrhythmia DAD I48, I495 In hospital ventricular arrhythmia DAD I490 In hospital heart failure DAD I50 In hospital ischemic stroke DAD I63 or I64 In hospital hemorrhagic stroke DAD I60, I61, I62 In hospital TIA DAD G45 In hospital pneumonia DAD J12, J13, J14, J15, J16, J17, J18, P23 In hospital pulmonary embolism DAD I26 In hospital DVT DAD I801; I802; I808; I822; I823; I828; I829 In hospital sepsis DAD R572, A41 Unplanned return to OR DAD Flag return to OR
5 Supplementary Digital Content Section D - Plot of Total Surgical Volume vs. Frail Surgical volume This plot shows the total number of surgical patients operated on in each hospital in the year before each index surgery on the Y-axis vs. the total number of frail surgical patients operated on in each hospital in the year before each index surgery on the x-axis. The grey-blue line represents the regression line fitted to the best linear relationship.
6 Supplementary Digital Content Section E Outcome model specifications and relative associations for all covariates Secondary outcome: Adverse events Covariate OR LCL UCL Frailty volume quintile 1 (lowestreference) (highest) Total volume quintile 1 (lowest-reference) (highest) Year of surgery (3 knot restricted cubic spline) Age (5 knot restricted spline) Female ( vs male) Rural (vs. not/none) Neighborhood income quintile 1 (lowest reference) (highest) Co-morbidities ASA score < 2 (reference) Alcohol abuse (vs. not/none) Atrial arrhythmia (vs. not/none) Blood loss anemia (vs. not/none) Cardiac valve disease (vs. not/none) Coagulopathy (vs. not/none) Chronic obstructive pulmonary disease Cerebrovascular disease (vs. not/none) Disease of pulmonary circulation (vs. not/none)
7 Dementia (vs. not/none) Depression (vs. not/none) Deficiency anemia (vs. not/none) Diabetes mellitus without complications (vs. not/none) Diabetes mellitus with complications (vs. not/none) Dialysis (vs. not/none) Drug abuse (vs. not/none) Heart failure (vs. not/none) Hemiplegia (vs. not/none) Hypertension with complications (vs. not/none) Hypertension without complications (vs. not/none) Liver disease (vs. not/none) Malignancy (vs. not/none) Metastases (vs. not/none) Obesity (vs. not/none) Peptic ulcer disease (vs. not/none) Peripheral vascular disease (vs. not/none) Psychoses (vs. not/none) Renal disease (vs. not/none) Rheumatic disease (vs. not/none) Venous thromboembolism (vs. not/none) Weight loss (vs. not/none) One-year mortality risk HOMR score (per 1 unit increase) Healthcare resource use Acute hospitalization in year prior to index admission (vs. not/none) Emergency department visit in year prior to index admission (vs. not/none) Procedure Total hip replacement (reference) Total knee replacement (vs. not/none) Carotid endarterectomy (vs. not/none) Endovascular AAA repair repair (vs. not/none) Open AAA repair (vs. not/none) Peripheral arterial bypass (vs. not/none) Nephrectomy (vs. not/none) Cystectomy (vs. not/none) Large bowel surgery (vs. not/none) Liver resection (vs. not/none) Pancreaticoduodenectomy (vs. not/none) Gastrectomy or esophagectomy (vs. not/none) Lobectomy or pneumonectomy (vs. not/none) AAA: Abdominal aortic aneurysm; ASA: American Society of Anesthesiologists; HOMR: Hospital One Year Mortality Risk; LCL: Lower Confidence Level (95%) OR: Odds Ratio; UCL: Upper Confidence Level (95%) Secondary outcome: Failure to rescue
8 Covariate OR LCL UCL Frailty volume quintile 1 (lowestreference) (highest) Total volume quintile 1 (lowest-reference) (highest) Year of surgery (3 knot restricted cubic spline) Age (5 knot restricted spline) Female ( vs male) Rural (vs. not/none) Neighborhood income quintile 1 (lowest reference) (highest) Co-morbidities ASA score < 2 (reference) Alcohol abuse (vs. not/none) Atrial arrhythmia (vs. not/none) Blood loss anemia (vs. not/none) Cardiac valve disease (vs. not/none) Coagulopathy (vs. not/none) Chronic obstructive pulmonary disease Cerebrovascular disease (vs. not/none) Disease of pulmonary circulation (vs. not/none) Dementia (vs. not/none) Depression (vs. not/none) Deficiency anemia (vs. not/none) Diabetes mellitus without complications (vs. not/none) Diabetes mellitus with complications (vs. not/none) Dialysis (vs. not/none) Drug abuse (vs. not/none) Heart failure (vs. not/none) Hemiplegia (vs. not/none) Hypertension with complications (vs. not/none) Hypertension without complications (vs. not/none) Liver disease (vs. not/none) Malignancy (vs. not/none)
9 Metastases (vs. not/none) Obesity (vs. not/none) Peptic ulcer disease (vs. not/none) Peripheral vascular disease (vs. not/none) Psychoses (vs. not/none) Renal disease (vs. not/none) Rheumatic disease (vs. not/none) Venous thromboembolism (vs. not/none) Weight loss (vs. not/none) One-year mortality risk HOMR score (per 1 unit increase) Healthcare resource use Acute hospitalization in year prior to index admission (vs. not/none) Emergency department visit in year prior to index admission (vs. not/none) Procedure Total hip replacement (reference) Total knee replacement (vs. not/none) Carotid endarterectomy (vs. not/none) Endovascular AAA repair repair (vs. not/none) Open AAA repair (vs. not/none) Peripheral arterial bypass (vs. not/none) Nephrectomy (vs. not/none) Cystectomy (vs. not/none) Large bowel surgery (vs. not/none) Liver resection (vs. not/none) Pancreaticoduodenectomy (vs. not/none) Gastrectomy or esophagectomy (vs. not/none) Lobectomy or pneumonectomy (vs. not/none) AAA: Abdominal aortic aneurysm; ASA: American Society of Anesthesiologists; HOMR: Hospital One Year Mortality Risk; LCL: Lower Confidence Level (95%) OR: Odds Ratio; UCL: Upper Confidence Level (95%) Secondary outcome: In-hospital costs Covariate IRR LCL UCL Frailty volume quintile 1 (lowestreference) (highest) Total volume quintile 1 (lowest-reference) (highest)
10 Year of surgery (3 knot restricted cubic spline) Age (5 knot restricted spline) Female ( vs male) Rural (vs. not/none) Neighborhood income quintile 1 (lowestreference) (highest) Co-morbidities ASA score < 2 (reference) Alcohol abuse (vs. not/none) Atrial arrhythmia (vs. not/none) Blood loss anemia (vs. not/none) Cardiac valve disease (vs. not/none) Coagulopathy (vs. not/none) Chronic obstructive pulmonary disease Cerebrovascular disease (vs. not/none) Disease of pulmonary circulation (vs. not/none) Dementia (vs. not/none) Depression (vs. not/none) Deficiency anemia (vs. not/none) Diabetes mellitus without complications (vs. not/none) Diabetes mellitus with complications (vs. not/none) Dialysis (vs. not/none) Drug abuse (vs. not/none) Heart failure (vs. not/none) Hemiplegia (vs. not/none) Hypertension with complications (vs. not/none) Hypertension without complications (vs. not/none) Liver disease (vs. not/none) Malignancy (vs. not/none) Metastases (vs. not/none) Obesity (vs. not/none) Peptic ulcer disease (vs. not/none) Peripheral vascular disease (vs. not/none) Psychoses (vs. not/none) Renal disease (vs. not/none) Rheumatic disease (vs. not/none) Venous thromboembolism (vs. not/none) Weight loss (vs. not/none) One-year mortality risk HOMR score (per 1 unit increase)
11 Healthcare resource use Acute hospitalization in year prior to index admission (vs. not/none) Emergency department visit in year prior to index admission (vs. not/none) Procedure Total hip replacement (reference) Total knee replacement (vs. not/none) Carotid endarterectomy (vs. not/none) Endovascular AAA repair repair (vs. not/none) Open AAA repair (vs. not/none) Peripheral arterial bypass (vs. not/none) Nephrectomy (vs. not/none) Cystectomy (vs. not/none) Large bowel surgery (vs. not/none) Liver resection (vs. not/none) Pancreaticoduodenectomy (vs. not/none) Gastrectomy or esophagectomy (vs. not/none) Lobectomy or pneumonectomy (vs. not/none) AAA: Abdominal aortic aneurysm; ASA: American Society of Anesthesiologists; HOMR: Hospital One Year Mortality Risk; LCL: Lower Confidence Level (95%) OR: Odds Ratio; UCL: Upper Confidence Level (95%)
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