The Surgical Assessment and Healthcare (SAH) Index: A Risk-Adjusted Framework for Surgeon-Level Quality Audit in Gastric Cancer
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Background
Gastric cancer management is heterogeneous, and although the treating surgeon leads decisions across the pathway, surgeon-level outcome variation remains poorly quantified. This study assessed surgeon identity as an independent predictor of survival after risk adjustment, introducing the Surgical Assessment and Healthcare (SAH) Index.
Methods
This single-institution retrospective study (Ruijin Hospital, Shanghai Jiao Tong University; NCT07180966 ) included 692 patients undergoing curative-intent resection for gastric adenocarcinoma (pStage I–III) in 2019 by eight consultant surgeons. Overall survival was modelled by multivariable Cox regression (primary model, 199 events, EPV 16.6; complete-case sensitivity model, N = 647). The SAH Index expressed surgeon × stage observed-to-expected ratios for five-year mortality and major morbidity (Clavien–Dindo ≥ IIIa). Median follow-up was 74.3 months.
Results
Independent predictors of survival were tumour stage (HR 2.979/step), age (HR 1.030/year), and non-distal gastrectomy (HR 1.498; all p ≤ .006). After full adjustment, surgeon identity remained significant (Wald = 14.58, df = 7, p = .042): two surgeons carried roughly double the reference hazard — S6 (HR 2.219, p = .003) and S8 (HR 2.034, p = .031) — both with the cohort’s lowest neoadjuvant chemotherapy rates (3.0% and 7.0% versus 17.6%), implicating pre-operative pathway decisions. The effect persisted in the sensitivity model (MSI also prognostic, HR 3.162, p = .007). Morbidity benchmarking flagged no surgeon for excess complications (no Tier 2 flags) and one survival-outlier cell (S6, Stage II; Tier 3).
Conclusion
Surgeon identity is independently associated with survival in gastric cancer beyond measurable case-mix. The SAH Index offers a reproducible tool for institutional and inter-hospital benchmarking, with tier assignments stable across all four prespecified weighting scenarios — confirming tier classification is independent of weight specification.
