ORIGINAL ARTICLE
Surgical Risk Preoperative Assessment System (SURPAS)
I. Parsimonious, Clinically Meaningful Groups of Postoperative
Complications by Factor Analysis
Robert A. Meguid, MD, MPH,  y Michael R. Bronsert, PhD, MS,  z Elizabeth Juarez-Colunga, PhD,  z
Karl E. Hammermeister, MD,  z and William G. Henderson, MPH, PhD  z
Objective: To use factor analysis to cluster the 18 American College of
Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
perioperative complications into a reproducible, smaller number of clinically
meaningful groups of postoperative complications, facilitating and stream-
lining future study and application in live clinical settings.
Background: The ACS NSQIP collects and reports on eighteen 30-day
postoperative complications (excluding mortality), which are variably
grouped in published analyses using ACS NSQIP data. This hinders com-
parison between studies of this widely used quality improvement dataset.
Methods: Factor analysis was used to develop a series of complication
clusters, which were then analyzed to identify a parsimonious, clinically
meaningful grouping, using 2,275,240 surgical cases in the ACS NSQIP
Participant Use File (PUF), 2005 to 2012. The main outcome measures are
reproducible, data-driven, clinically meaningful clusters of complications
derived from factor solutions.
Results: Factor analysis solutions for 5 to 9 latent factors were examined for
their percent of total variance, parsimony, and clinical interpretability.
Applying the first 2 of these criteria, we identified the 7-factor solution,
which included clusters of pulmonary, infectious, wound disruption, cardiac/
transfusion, venous thromboembolic, renal, and neurological complications,
as the best solution for parsimony and clinical meaningfulness. Applying the
last (clinical interpretability), we combined the wound disruption with the
infectious clusters resulting in 6 clusters for future clinical applications.
Conclusions: Factor analysis of ACS NSQIP postoperative complication data
provides 6 clinically meaningful complication clusters in lieu of 18
From the Surgical Outcomes and Applied Research Program, University of
Colorado School of Medicine, Aurora; yDepartment of Surgery, University
of Colorado School of Medicine, Aurora; zAdult and Child Center for Health
Outcomes Research and Delivery Science, University of Colorado School of
Medicine, Aurora; Department of Biostatistics and Informatics, Colorado
School of Public Health, Aurora; and Division of Cardiology, Department of
Medicine, University of Colorado School of Medicine, Aurora.
Robert A. Meguid and Michael Bronsert are co-first authors.
The present study was supported by the Department of Surgery, Adult and Child
Center for Health Outcomes Research and Delivery Science Joint Surgical
Outcomes and Applied Research Program at the University of Colorado, and
by Dr Meguids Academic Enrichment fund from the Department of Surgery.
Disclosure: All of the authors had full access to all of the data in the study and take
responsibility for the integrity of the data and the accuracy of the data analysis.
The American College of Surgeons National Surgical Quality Improvement
Program and participating hospitals are the source of these data; they have not
verified and are not responsible for the statistical validity of the data analysis or
the conclusions derived by the authors. The authors report no conflicts of
interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journals Web site (www.annalsofsurgery.com).
Reprints: Robert A. Meguid, MD, MPH FACS, Division of Cardiothoracic Surgery,
Department of Surgery, University of Colorado Denver, Anschutz Medical
Campus, 12631 E 17th Ave, C-310, Aurora, CO 80045.
E-mail: ROBERT.MEGUID@UCDenver.edu.
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/14/26105-0821
DOI: 10.1097/SLA.0000000000001669
1042 | www.annalsofsurgery.com
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
postoperative morbidities, which will facilitate comparisons and clinical
implementation of studies of postoperative morbidities.
Keywords: data-driven clustering of surgical outcomes, factor analysis,
postoperative risk prediction models, surgical outcomes, surgical risk
assessment
(Ann Surg 2016;263:10421048)
T he American College of Surgeons National Surgical Quality
Improvement Program (ACS NSQIP) collects data on patient
preoperative characteristics, aspects of the operation, and adverse
surgical outcomes from patients undergoing major operations at
participating hospitals. These adverse surgical outcomes are then
risk-adjusted and provided to the participating hospitals to facilitate
credible comparisons between centers. Based on the current ACS
NSQIP Essentials Work Sheet (July 2013), the adverse surgical
outcomes include 30-day mortality plus the following 18 postoper-
ative complications: acute renal failure requiring dialysis, deep
incisional surgical site infection (SSI), intra- or postoperative cardiac
arrest requiring cardiopulmonary resuscitation (CPR), intra- or post-
operative myocardial infarction, intra- or postoperative unplanned
intubation, on ventilator >48 hours, organ/space SSI, pneumonia,
progressive renal insufficiency, pulmonary embolism (PE), sepsis,
septic shock, stroke/cerebral vascular accident (CVA), superficial
SSI, transfusion intra/postoperatively, urinary tract infection (UTI),
vein thrombosis requiring therapy, and wound disruption. In prior
years, the ACS NSQIP also collected morbidity outcome data on
coma >24 hours, graft/prosthesis/flap failure, and peripheral nerve
injury, totaling 21 complications in earlier datasets. Unplanned
reoperation and readmission were not included with complications
because they are considered end results of other complications
measured in the above list.
Because NSQIP data have become available, numerous stud-
ies have used them to examine the surgical outcomes for various
patient populations and after different surgical interventions. There is
considerable variation in the literature as to how the NSQIP peri-
operative complications have been analyzed and reported. Some
studies have reported results for each of the 18 to 21 complications
plus mortality individually18; many have reported an overall mor-
bidity rate combining all of the complications together (percent of
patients with 1 complications); some have separated the compli-
cations into major or minor clusters2,6,9 13; and some have grouped
complications into clinical clusters.14 25 Given that up to 22 different
complications (when death is included) may be analyzed in a single
study, reporting the results for each individual complication requires
lengthy tables, is difficult to interpret, and ignores the correlations
between the complications. Reporting on one or more complications
provides a summary measure, but results in a very heterogeneous
outcome, making results difficult to interpret and act upon clinically.
The articles dividing outcomes into major and minor complications
Annals of Surgery  Volume 263, Number 6, June 2016
Annals of Surgery  Volume 263, Number 6, June 2016
often lack an objective justification for the classification (eg, using
criteria such as concomitant 30-day mortality or prolonged length of
stay). The clinical clusters of complications are useful for the
purposes of potentially intervening on processes of care to reduce
the complication rates. However, these clusters have often seemed
arbitrary and vary between studies. The use of these arbitrary,
dissimilar complication groups makes it difficult to compare com-
plication rates across studies, and to plan interventions to attempt to
reduce complication rates. To our knowledge, no attempt has been
made to cluster complications using factor analysis.
The purpose of this study is to develop clusters of the NSQIP
postoperative complications using factor analysis. This is a statistical
technique, which uses the correlation matrix of all variables (in our
case, complications scored as 0 absent or 1 present) across the
entire population to cluster the variables that have high correlations
with one another. Factor analysis has been used in surgical outcomes
research for the analysis of symptom scores and quality of life
measures in surgical patients. Some examples include the Michigan
Hand Questionnaire for assessing outcomes in hand surgery,26 the
M.D. Anderson Symptom Inventory in surgical oncology,27 the
Oxford Knee Score in knee replacement surgery,28 a postdischarge
surgical recovery scale in outpatient surgery,29 preoperative psycho-
logical assessments of bariatric surgical patients,30 32 and a pediatric
surgical outcomes assessment.33 We hypothesize that factor analysis
of the currently collected 18 postoperative complications (excluding
mortality) in the ACS NSQIP dataset will result in reproducible,
smaller numbers of clinically meaningful groups of postoperative
complications.
METHODS
Data
This study includes 98.0% (2,275,240/2,320,936) of patients
in the ACS NSQIP PUF for the years 2005 to 2012; 2.0% (45,680/
2,320,936) of cases have been excluded because of missing data and
surgical specialties no longer included in the ACS NSQIP PUF. Of
those records excluded, 15,581 (0.7%) were not in targeted surgical
specialties, and the remainder were missing key data as follows: 7659
(0.3%) were missing transfer status, 7269 (0.3%) were missing
American Society of Anesthesiology physical status classification,
5758 (0.3%) were missing Current Procedural Terminology code
from which work relative value unit is derived, 5301 (0.2%) were
missing functional health status, 3993 (0.2%) were missing sex, and
119 (0.01%) were missing other data. The ACS NSQIP PUF has been
widely used and is recognized as a reliable and valid clinical
registry.34,35 The ACS NSQIP collects data on a representative
sample of patients undergoing major surgery from member hospitals.
Patient demographics, preoperative risk factors, variables describing
the operation, and mortality and complications for 30 days after
surgery are abstracted by highly trained nurse clinical reviewers. The
reproducibility of this data abstraction is periodically checked by
repeat abstraction of a sample. All 18 currently collected compli-
cations in the ACS NSQIP PUF were analyzed. The Colorado
Multiple Institutional Review Board determined this study exempt
from review as it uses publicly available de-identified data.
Factor Analysis
The primary goal of our factor analysis was to arrive at a more
parsimonious and clinically meaningful subset of complications by
clustering those complications correlated with one another. Factor
analysis begins with the correlation matrix of the measured variables;
in this case, an 18  18 matrix with the elements representing the
correlations between any 2 pairs of postoperative complications
scored as present or absent. Factor analysis then transforms this
2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Clustering of ACS NSQIP Complications
matrix into another matrix of linear combinations of the observed
variables, termed latent factors. The first factor accounts for the
largest proportion of the total variance of the 18 observed variables;
the second factor accounts for the next largest proportion of total
variance, and so on. Each factor has an eigenvalue representing the
amount of variance accounted for by that factor. In general, deter-
mining the number of factors for any set of measured variables is
somewhat subjective, but a common approach is to retain only the
factors that have eigenvalues at least 1.0.36 Another desirable attrib-
ute is for the factors selected to account for a large percentage of the
total variance of the measured variables, ideally 50% or more.37
Once the number of factors to retain in the solution is determined, the
loadings for each factor (ie, the correlations of each measured
variable with the underlying factor) are examined to identify the
underlying nature of that factor.
We evaluated several incremental factor solutions, beginning
with the solution having eigenvalues of at least 1 for all factors, and
stopping when the solutions began to lose parsimony by having many
single-complication factors. A varimax rotation was also applied to
each factor solution. The varimax rotation is used to improve the
interpretability of each factor by increasing the large factor loadings
and decreasing the small factor loadings for each factor.38 All
analyses were performed using SAS software version 9.3 (SAS
Inc, Cary, NC).
RESULTS
Patient and operative characteristics of the sample are pre-
sented in Supplemental Digital Content 1: Preoperative Patient
Characteristics (http://links.lww.com/SLA/A980). The 30-day all-
cause mortality rate was 1.4% (31,568/2,275,240), and 1 or more
complications occurred in 12.6% (287,012/2,275,240). The most
prevalent complications were transfusion intra-/postoperatively
(4.3%), superficial SSI (2.4%), on ventilator greater than 48 hours
(1.8%), sepsis (1.7%), UTI (1.6%), and pneumonia (1.4%). A total of
87.4% (1,988,228) of the patients had no postoperative compli-
cations, 8.4% (190,599) had 1 postoperative complication, and
4.2% (96,413) had 2 or more complications.
Factor Analysis
Table 1 presents the eigenvalues for each factor of the factor
analysis of the 18 complications along with the proportion and
cumulative proportion of the total variance explained by each one.
The first 5 factors had eigenvalues greater than 1.0 but only
accounted for 40% of the total variance of the 18 postoperative
complications. The 7-factor solution accounted for more than 50%
and the 9-factor solution accounted for more than 60% of the total
variance of the observed variables, but these factor solutions had
some factors with eigenvalues below 1.0. Figure 1 presents a graph of
eigenvalues and percent of total variance accounted for. The graph
shows that we can choose factor solutions that account for at least
50% to 60% of the total variance and still have all factors with
eigenvalues 1.0 or more, or close in magnitude to 1.0.
A final consideration in the selection of the factor solution is
clinical interpretability of the factors. Table 2 presents the factor
loadings (ie, the correlations between the complications and each
underlying latent factor) after varimax rotation. In Table 2, we
present the complications with the highest factor loadings for each
underlying latent factor within each solution. The 5- and 6-factor
solutions only accounted for 40% to 46% of the total variance,
resulted in clusters that were not clearly clinically meaningful (eg,
clustering pulmonary and renal complications together), and had
some low factor loadings (eg, 0.20 or 0.28 for progressive renal
insufficiency). The 7- and 8-factor solutions accounted for more of
the total variance (51% to 56%), and the clusters were more clinically
www.annalsofsurgery.com | 1043
Meguid et al Annals of Surgery  Volume 263, Number 6, June 2016

organ/space SSI, UTI, and superficial SSI; (3) A venous thromboem-

FIGURE 1. Factors and Cumulative Proportion of Variance in
the Correlation Matrix of the 18 ACS NSQIP Complications.
interpretable. The 9-factor solution resulted in 3 instances of single
complications loading on 1 factor (UTI, superficial SSI, and stroke/
CVA), and thus was not as parsimonious as the other factor solutions.
This happened because the average correlations of these compli-
cations with the remaining 17 postoperative complications were
relatively low; the average correlations ranged from 0.027 for
superficial SSI, 0.031 for stroke/CVA, and 0.053 for UTI, up to
0.133 for septic shock, 0.143 for intra- or postoperative unplanned
intubation, and 0.166 for on ventilator more than 48 hours.
Given the desire to develop a parsimonious number of com-
plication clusters that are clinically interpretable, we favor the use of
the 7-factor solution. This solution was similar to the 8-factor
solution, with the exception of superficial SSI residing as its own
factor in the 8-factor solution, in addition to stroke/CVA, which is its
own factor in both the 7- and the 8-factor solution.
This 7-factor solution consists of the following 7 clusters: (1)
A pulmonary complication cluster: on ventilator for more than
48 hours, intra- or postoperative unplanned intubation, septic shock,
and pneumonia; (2) An infectious complication cluster: sepsis,
bolic complication cluster: vein thrombosis requiring therapy and
PE; (4) A wound disruption complication cluster: deep incisional SSI
and wound disruption; (5) A cardiac/transfusion complication clus-
ter: transfusion intra-/postoperatively, intra- or postoperative myo-
cardial infarction, and intra- or postoperative cardiac arrest requiring
CPR; (6) A renal complication cluster: acute renal failure and
progressive renal insufficiency; and (7) A single complication form-
ing the neurological complication cluster: stroke/CVA.
To further explore why we observed 2 infectious factors in the
7-factor solution (factors 2 and 4), we analyzed the correlations
between the 6 complications loading onto these 2 factors: UTI,
superficial SSI, deep incisional SSI, organ/space SSI, wound dis-
ruption, and sepsis (Table 3). This analysis demonstrated that sepsis
most closely correlated with organ/space SSI (0.281), UTI (0.164),
deep incisional SSI (0.125), and superficial SSI (0.106). Deep inci-
sional SSI and wound disruption have a relatively large correlation
(0.144); and superficial, deep incisional, and organ/space SSI have
very low correlations among themselves (0.0070.033), an indica-
tion that if 1 is scored as present, the other 2 are scored as absent.
Because potential processes of care to prevent infection are likely to
be similar for factor 2 (sepsis, organ/space SSI, UTI, and superficial
SSI) and factor 4 (deep SSI and wound disruption), we decided to
combine these 2 factors into a single infectious complication cluster.
All 6 clusters and included complications are summarized in Table 4.
DISCUSSION
To our knowledge, this is the first study using factor analysis
on the ACS NSQIP data to help define clusters of postoperative
complications. We have taken an empirical approach to clustering of
complications, using a well-accepted statistical methodology, factor
analysis, to identify clusters of ACS NSQIP postoperative compli-
cations that are correlated with one another. We examined 5 different
solutions, from a 5-factor solution that included all factors with
eigenvalues greater than 1.0 to a 9-factor solution that accounted for
over 60% of the total variance of the 18 postoperative complications.
In comparing the different solutions, we found that the 7-factor
solution exhibited both good parsimony and clinical interpretability.
Clinical judgment indicated that all 6 complications in factors 2 and 4
were infectious in origin and likely to be affected by similar care

TABLE 1. Factors and Proportion of Variance in the Correlation Matrix of the 18 ACS NSQIP Complications Studied
Factor Number Eigenvalue Proportion of Total Variance Explained, % Cumulative Proportion Total Variance Explained, %
1 2.6561 14.76 14.76
2 1.3344 7.41 22.17
3 1.1281 6.27 28.44
4 1.0648 5.92 34.35
5 1.0258 5.70 40.05
6 0.9926 5.51 45.57
7 0.9860 5.48 51.04
8 0.9771 5.43 56.47
9 0.9476 5.26 61.74
10 0.9351 5.19 66.93
11 0.9061 5.03 71.96
12 0.8726 4.85 76.81
13 0.8618 4.79 81.60
14 0.8294 4.61 86.21
15 0.7654 4.25 90.46
16 0.6455 3.59 94.05
17 0.5757 3.20 97.24
18 0.4960 2.76 100.00

1044 | www.annalsofsurgery.com 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.


TABLE 2. Largest Factor Loadings After Varimax Rotation for the 18 ACS NSQIP Complications Studied for 5 Different Factor Solutions
Factor/Group Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7 Factor 8 Factor 9
On vent 0.75 Sepsis 0.74 PE 0.78 Deep SSI 0.77 MI 0.68
Septic shock 0.71 Organ/space SSI 0.61 DVT 0.74 Wnd dsrptn 0.73 Tfx 0.43
Unpl intbtn 0.68 UTI 0.49 Stroke 0.43
5-Factor Solution Pneumonia 0.58 Sprfcl SSI 0.36 Card arrest 0.39
ARF 0.47
Prg rnl insf 0.28
On vent 0.75 Sepsis 0.75 PE 0.78 Deep SSI 0.77 MI 0.68 Stroke 0.70

2016 Wolters Kluwer Health, Inc. All rights reserved.

Unpl intbtn 0.70 Organ/space SSI 0.63 DVT 0.74 Wnd dsrptn 0.73 Tfx 0.50
Septic shock 0.69 UTI 0.48 Card arrest 0.38
Annals of Surgery  Volume 263, Number 6, June 2016

6-Factor Solution Pneumonia 0.59 Sprfcl SSI 0.33

ARF 0.43
Prg rnl insf 0.20
On vent 0.74 Sepsis 0.75 PE 0.78 Deep SSI 0.78 MI 0.72 Prg rnl insf 0.74 Stroke 0.88
Unpl intub 0.71 Organ/space SSI 0.66 DVT 0.74 Wnd dsrptn 0.72 Card arrest 0.52 ARF 0.44
7-Factor Solution Septic shock 0.68 UTI 0.44 Tfx 0.40
Pneumonia 0.59 Sprfcl SSI 0.35
On vent 0.74 Sepsis 0.75 PE 0.78 Deep SSI 0.78 MI 0.75 Prg rnl insf 0.74 Sprfcl SSI 0.97 Stroke 0.92
Unpl intub 0.72 Organ/space SSI 0.71 DVT 0.74 Wnd dsrptn 0.72 Card arrest 0.54 ARF 0.45
8-Factor Solution Septic shock 0.69 UTI 0.44 Tfx 0.44
Pneumonia 0.60
On vent 0.74 Organ/space SSI 0.86 PE 0.78 Deep SSI 0.78 MI 0.77 Prg rnl insf 0.83 UTI 0.88 Sprfcl SSI 0.97 Stroke 0.98
Unpl intub 0.72 Sepsis 0.70 DVT 0.74 Wnd dsrptn 0.72 Card arrest 0.54 ARF 0.48
9-Factor Solution Septic shock 0.68 Tfx 0.42
Pneumonia 0.63
ARF indicates acute renal failure requiring dialysis; Card arrest, intra- or postoperative cardiac arrest requiring cardiopulmonary resuscitation; DVT, vein thrombosis requiring therapy; MI, intra- or postoperative myocardial
infarction; On vent, on ventilator >48 hours; PE, pulmonary embolism; Prg rnl insf, progressive renal insufficiency; Sprfcl, superficial; SSI, surgical site infection; Stroke, stroke/cerebral vascular accident; Tfx, transfusion intra-/
postoperatively; Unpl intub, intra- or postoperative unplanned intubation; Wnd dsrptn, wound disruption.

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

Clustering of ACS NSQIP Complications

www.annalsofsurgery.com | 1045
Meguid et al Annals of Surgery  Volume 263, Number 6, June 2016

TABLE 3. Correlation Matrix of Postoperative Wound Infection Complications

Complication Sepsis UTI Superficial SSI Organ Space SSI Deep Incisional SSI Wound Disruption
Sepsis 1.00
UTI 0.164 1.00
Superficial SSI 0.106 0.039 1.00
Organ/space SSI 0.281 0054 0.033 1.00
Deep incisional SSI 0.125 0.034 0.007 0.017 1.00
Wound disruption 0.080 0.031 0.056 0.074 0.144 1.00

Correlations discussed in narrative are indicated in bold.

processes, so we combined the complications in these 2 factors into a
single group.
In reviewing the literature, we have found that investigators
group and analyze the ACS NSQIP postoperative complications in
many different ways, often without providing justification. Our study
addressed data-driven development of a limited number of clusters of
postoperative complications based on the ACS NSQIP dataset of
2,275,240 procedures between 2005 and 2012. Our use of factor
analysis and clinical judgment to reduce the 18 ACS NSQIP com-
plications to 6 clusters facilitates clinicians and investigators in
summarizing potential adverse outcomes for communication to
patients, and enabling identification of potentially actionable proc-
esses of care to reduce risk in high-risk patients. We hypothesize that
complications within a cluster are more likely to have a common
pathophysiologic mechanism than those not, meaning that they may
also share successful intervention(s).
Our data-driven complication clusters have the potential to
create more parsimony and standardization in the analysis and
reporting of ACS NSQIP postoperative complications, to permit
development of statistical models to predict the risk of developing
these complications, and to study processes and structures of surgical
care that can be implemented to reduce the risk of these compli-
cations in high-risk patients.
TABLE 4. Frequency and Occurrence Rates of Recommended
Clusters and Their Included Complications
Clusters Based on 7-Factor
Solution and Clinical Judgment
Infectious complications cluster (factors 2 and 4) 148,837
SSI
Deep incisional SSI
Wound disruption
Organ/space SSI
Sepsis
UTI
Cardiac/transfusion complications cluster (factor 5) 108,585
Transfusion intra-/postoperatively
Intra- or postoperative myocardial infarction
Intra- or postoperative cardiac arrest requiring CPR
Pulmonary complications cluster (factor 1)
On ventilator >48 h
Intra- or postoperative unplanned intubation
Septic shock
Pneumonia
Venous thromboembolic complications cluster (factor 3)
Vein thrombosis requiring therapy
Pulmonary embolism
Renal complications cluster (factor 6)
Acute renal failure requiring dialysis
Progressive renal insufficiency
Neurological complication cluster (factor 7)
Stroke/cerebral vascular accident
The factor analysis solution resulting in 7 complication clus-
ters generally follows clinical logic, with some relationships more
clear than others. The pulmonary complication cluster includes
related complications of intra- or postoperative unplanned intuba-
tion, on ventilator for greater than 48 hours, and pneumonia. These
are often clinically interrelated with prolonged intubation putting
patients at risk of ventilator-associated pneumonia, or development
of pneumonia resulting in intra- or postoperative unplanned intuba-
tion. That septic shock is combined with these may be clinically
understood as both a sequel of pneumonia and resulting in intra- or
postoperative unplanned intubation and on ventilator for more than
48 hours. Although sepsis and septic shock occur on a clinical
continuum, they are mutually exclusive complications according
to the ACS NSQIP definitions. Therefore, while a patient may
experience concurrent complications, infectious or otherwise, they
may not have both sepsis and septic shock during the same encounter.
Because of this coding limitation, their occurrence cannot be corre-
lated with each other resulting in septic shock appearing in factor 1
and sepsis in factor 2 (Table 2). The venous thromboembolic
complication cluster includes vein thrombosis requiring treatment
and pulmonary embolism, separately measured adverse outcomes in
the ACS NSQIP, but clearly the latter is usually the result of the
former. The cardiac/transfusion intra-/postoperatively complication
cluster includes clinically interrelated intra- or postoperative myo-
cardial infarction and intra- or postoperative cardiac arrest requiring
CPR. Transfusion intra-/postoperatively is more difficult to explain,
but may relate to the frequent use of anticoagulants in myocardial
infarction and cardiac arrest. The renal complication cluster includes
Number, % both acute renal failure requiring dialysis and progressive renal
(6.5) insufficiency, clearly a clinical spectrum of disease albeit with
53,952 (2.4) different long-term impact. The infectious complications separated
15,789 (0.7) out into 2 clusters: UTI, superficial SSI, organ/space SSI, and sepsis;
11,960 (0.5) and deep incisional SSI and wound disruption. To better understand
27,224 (1.2)
why these divided into 2 separate clusters, we examined a correlation
39,212 (1.7)
37,098 (1.6)
matrix of only these 6 complications (Table 3). We found that UTI,
(4.8) superficial SSI, and organ/space SSI correlated most highly with
96,673 (4.3) sepsis. Although deep incisional SSI correlated with sepsis, it
7848 (0.3) correlated more strongly with wound disruption. The latter demon-
9150 (0.4) strates that deep incisional SSI is associated with both wound
74,600 (3.3) disruption and sepsis; the NSQIP definitions distinctly separate
41,179 (1.8) the different SSIs, which may in fact occur on a continuum clinically.
27,535 (1.2) We argue that clinically one could combine all of these 6 infectious
21,319 (0.9) complications together into a single cluster, particularly if similar
31,598 (1.4)
20,674 (0.9)
processes and structures of surgical care intervention could reduce
15,031 (0.7) the risk of these complications in high-risk patients. The neurological
7417 (0.3) complication cluster contains stroke/CVA. This single complication
15,857 (0.7) stands alone because it did not correlate well with any of the other
9337 (0.4) complications. Our adoption of the 7-factor solution (plus combining
7425 (0.3) factors 2 and 4 as an infectious cluster) results in a relatively
5120 (0.2) parsimonious group of complications and generally agrees with
5120 (0.2) clinical logic.

1046 | www.annalsofsurgery.com 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

Annals of Surgery  Volume 263, Number 6, June 2016
The purpose of this study has been to cluster the NSQIP
postoperative complications to reduce the number of postoperative
adverse outcomes in the design of a preoperative risk assessment and
decision support system (Surgical Risk Preoperative Assessment
System - SURPAS). Factor analysis provides a statistical solution
to the issue of how to cluster postoperative complications by
clustering those complications that tend to occur together. As we
further develop the SURPAS tool, we might find that different
processes of care affect the development of the different compli-
cations that are statistically clustered together (eg, UTI and SSI, or
transfusion intra-/postoperatively and the cardiac complications of
intra- or postoperative myocardial infarction and intra- or postoper-
ative cardiac arrest requiring CPR). In these cases, we might need to
consider developing separate risk prediction models for some of the
individual complications and thus add to the number of outcomes
reported to the surgical teams and patients.
We believe that our study adds to the current ACS NSQIP
literature in terms of resolving which complications should be
clustered together. For example, 1 study combined pneumonia with
other infectious complications,25 but our data-driven analysis
suggests that pneumonia should be combined with the other
pulmonary complications; some studies have combined stroke/
CVA with cardiac complications,20 22 but our analyses suggest
that stroke/CVA does not correlate well with any other compli-
cations; some studies have combined PE with other pulmonary
complications,18 22 but our analyses suggest that PE should be
combined with vein thrombosis requiring therapy; and some
studies have combined UTI with renal complications,18,19,22 24
but our analyses suggest that UTI is more closely associated with
other infections.
This study has some important strengths and a few limitations.
The strengths include the following: (1) Use of a large and validated
clinical database; and (2) To our knowledge, the first application of
factor analysis to provide a more objective and replicable clustering
of ACS NSQIP-reported postoperative complications. Potential
limitations include those related to the sampling of surgical oper-
ations in the ACS NSQIP: (1) Possibly an over-representation of
general surgical and vascular operations; and (2) An over-repres-
entation of university and large community hospitals. It was not our
intent to reduce the collection of postoperative outcomes in NSQIP,
but rather to reduce the number of patient risk scores for post-
operative adverse outcomes to streamline patient and provider
education and guide further perioperative intervention to decrease
adverse postoperative outcomes.
The development of the ACS NSQIP provides us with an
opportunity to evaluate specific outcomes, not previously available
through such a large database. However analysis of the numerous
different outcomes requires considerable effort and resources and
may lead to confusion in interpretation. Prior authors have attempted
to cluster different outcomes into smaller groups to facilitate data
analysis. However this has been without consensus and without
support of the data. We have used factor analysis and clinical
judgment to define six clinically interpretable complication clusters
in lieu of the 18 ACS NSQIP postoperative morbidities. This is
intended to serve as the foundation for subsequent studies developing
prediction models for a parsimonious set of surgical outcomes in
support of a Surgical Risk Preoperative Assessment System that we
call SURPAS.
REFERENCES
1. Goldfarb M, Perry Z, Hodin A, et al. Medical and surgical risks in thyroid
surgery: lessons from the NSQIP. Ann Surg Oncol. 2011;18:35513558.
2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Clustering of ACS NSQIP Complications
2. Gupta PK, Miller WJ, Sainath J, et al. Determinants of resource utilization and
outcomes in laparoscopic Roux-en-Y gastric bypass: a multicenter analysis of
14,251 patients. Surg Endosc. 2011;25:26132625.
3. Gupta PK, Turaga KK, Miller WJ, et al. Determinants of outcomes in
pancreatic surgery and use of hospital resources. J Surg Oncol. 2011;
104:634640.
4. Gupta PK, Smith RB, Gupta H, et al. Outcomes after thyroidectomy and
parathyroidectomy. Head Neck. 2012;34:477484.
5. Ismael H, Horst M, Farooq M, et al. Adverse effects of preoperative steroid use
on surgical outcomes. Am J Surg. 2011;201:305308.
6. Kim MJ, Fleming FJ, Gunzler DD, et al. Laparoscopic appendectomy is safe
and efficacious for the elderly: an analysis using the National Surgical Quality
Improvement Project database. Surg Endosc. 2011;25:18021807.
7. Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and
mortality of bariatric surgical procedures as assessed by prospective, multi-
center, risk-adjusted ACS-NSQIP data. Surg Endosc. 2008;22:25542563.
8. Lidor AO, Chang DC, Feinberg RL, et al. Morbidity and mortality associated
with antireflux surgery with or without paraesophogeal hernia: a large ACS
NSQIP analysis. Surg Endosc. 2011;25:31013108.
9. Al-Refaie WB, Parsons HM, Habermann EB, et al. Operative outcomes
beyond 30-day mortality: colorectal cancer surgery in oldest old. Ann Surg.
2011;253: 947952.
10. Belmont PJ Jr, Davey S, Orr JD, et al. Risk factors for 30-day postoperative
complications and mortality after below-knee amputation: a study of 2,911
patients from the national surgical quality improvement program. J Am Coll
Surg. 2011;213:370378.
11. Fleming FJ, Kim MJ, Gunzler D, et al. Its the procedure not the patient: the
operative approach is independently associated with an increased risk of
complications after rectal prolapse repair. Colorectal Dis. 2012;14:362368.
12. Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative factors predict
perioperative morbidity and mortality after pancreaticoduodenectomy. Ann
Surg Oncol. 2011;18:21262135.
13. Kelly KJ, Greenblatt DY, Wan Y, et al. Risk stratification for distal pancrea-
tectomy utilizing ACS-NSQIP: preoperative factors predict morbidity and
mortality. J Gastrointest Surg. 2011;15:250259.
14. Advani V, Ahad S, Gonczy C, et al. Does resident involvement effect surgical
times and complication rates during laparoscopic appendectomy for uncom-
plicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP. Am J
Surg. 2012;203:347351.
15. Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the
universal ACS NSQIP surgical risk calculator: a decision aid and informed
consent tool for patients and surgeons. J Am Coll Surg. 2013;217:833842.
16. Davenport DL, Xenos ES. Early outcomes and risk factors in venous throm-
bectomy: an analysis of the American College of Surgeons NSQIP dataset.
Vasc Endovascular Surg. 2011;45:325328.
17. Greenblatt DY, Rajamanickam V, Pugely AJ, et al. Short-term outcomes after
laparoscopic-assisted proctectomy for rectal cancer: results from the ACS
NSQIP. J Am Coll Surg. 2011;212:844854.
18. Kazaure HS, Roman SA, Sosa JA. Obesity is a predictor of morbidity in 1,629
patients who underwent adrenalectomy. World J Surg. 2011;35:12871295.
19. Kazaure HS, Roman SA, Sosa JA. The resident as surgeon: an analysis of
ACS-NSQIP. J Surg Res. 2012;178:126132.
20. Leichtle SW, Kaoutzanis C, Mouawad NJ, et al. Classic Whipple versus
pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP. J Surg Res.
2013;183:170176.
21. Liu JJ, Maxwell BG, Panousis P, et al. Perioperative outcomes for laparoscopic
and robotic compared with open prostatectomy using the National Surgical
Quality Improvement Program (NSQIP) database. Urology. 2013;82:579
583.
22. Suleiman LI, Ortega G, Onguti SK, et al. Does BMI affect perioperative
complications following total knee and hip arthroplasty? J Surg Res.
2012;174:711.
23. Thomas DC, Roman SA, Sosa JA. Parathyroidectomy in the elderly: analysis
of 7313 patients. J Surg Res. 2011;170:240246.
24. Turan A, Yang D, Bonilla A, et al. Morbidity and mortality after massive
transfusion in patients undergoing non-cardiac surgery. Can J Anaesth.
2013;60:761770.
25. Uppal S, Al-Niaimi A, Rice LW, et al. Preoperative hypoalbuminemia is an
independent predictor of poor perioperative outcomes in women undergoing
open surgery for gynecologic malignancies. Gynecol Oncol. 2013;131:416
422.
26. Chung BT, Morris SF. Confirmatory factor analysis of the Michigan Hand
Questionnaire. Ann Plast Surg. 2015;74:176181.
www.annalsofsurgery.com | 1047
Meguid et al
27. Sailors MH, Bodurka DC, Gning I, et al. Validating the M. D. Anderson
Symptom Inventory (MDASI) for use in patients with ovarian cancer. Gynecol
Oncol. 2013;130:323328.
28. Harris K, Dawson J, Doll H, et al. Can pain and function be distinguished in the
Oxford Knee Score in a meaningful way? An exploratory and confirmatory
factor analysis. Qual Life Res. 2013;22:25612568.
29. Berg K, Idvall E, Nilsson U, et al. Psychometric evaluation of the post-
discharge surgical recovery scale. J Eval Clin Pract. 2010;16:794801.
30. Corsica JA, Azarbad L, McGill K, et al. The Personality Assessment Inven-
tory: clinical utility, psychometric properties, and normative data for bariatric
surgery candidates. Obes Surg. 2010;20:722731.
31. Hall BJ, Hood MM, Nackers LM, et al. Confirmatory factor analysis of the
Beck Depression Inventory-II in bariatric surgery candidates. Psychol Assess.
2013;25:294299.
32. Mahony D. Psychological assessments of bariatric surgery patients. Develop-
ment, reliability, and exploratory factor analysis of the PsyBari. Obes Surg.
2011;21:13951406.
1048 | www.annalsofsurgery.com
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 263, Number 6, June 2016
33. Allen DD, Gorton GE, Oeffinger DJ, et al. Analysis of the pediatric outcomes
data collection instrument in ambulatory children with cerebral palsy using
confirmatory factor analysis and item response theory methods. J Pediatr
Orthop. 2008;28:192198.
34. Raval MV, Hamilton BH, Ingraham AM, et al. The importance of assessing
both inpatient and outpatient surgical quality. Ann Surg. 2011;253:611618.
35. Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information:
data quality and inter-rater reliability in the American College of Surgeons
National Surgical Quality Improvement Program. J Am Coll Surg.
2010;210:616.
36. Kaiser HF. The application of electronic computers to factor analysis. Educ
Psychol Meas. 1960;20:141151.
37. Velicer WF, Jackson DN. Component analysis versus common factor analysis
some further observations. Multivariate Behav Res. 1990;25:97114.
38. Bauer JD, Jackson A, Skwarchuk M, et al. Principal component, Varimax
rotation and cost analysis of volume effects in rectal bleeding in patients
treated with 3D-CRT for prostate cancer. Phys Med Biol. 2006;51:51055123.
2016 Wolters Kluwer Health, Inc. All rights reserved.