System-based factors influencing intraoperative decision-making in rectal cancer by surgeons: An international assessment

Aim Sound surgical judgement is the goal of training and experience; however, system-based factors may also colour selection of options by a surgeon. We analysed potential organizational characteristics that might influence rectal cancer decision-making by an experienced surgeon. Method One hundred and seventy-three international centres treating rectal cancer were invited to participate in a survey assessment of key treatment options for patients undergoing curative rectal-cancer surgery. The key organizational characteristics were analysed using multivariate methods for association with intra-operative surgical decision-making. Results The response rate was 71% (123 centres). Sphincter-saving surgery was more likely to be performed at university hospitals (OR=3.63, P=0.01) and by high-caseload surgeons (OR=2.77 P=0.05). A diverting stoma was performed more frequently in departments with clinical audits (OR=3.06, P=0.02), and a diverting stoma with coloanal anastomosis was more likely in European centres (OR=4.14, P=0.004). One-stage surgery was less likely where there was assessment by a multidisciplinary team (OR=0.24, P=0.02). Multivariate analysis showed that university hospital, clinical audit, European centre, multidisciplinary team and high caseload significantly impacted on surgical decision-making. Conclusion Treatment variance of rectal cancer surgeons appears to be significantly influenced by organizational characteristics and complex team-based decision-making. System-based factors may need to be considered as a source of outcome variation that may impact on quality metrics.