Surgical Endoscopy

, Volume 32, Issue 6, pp 2886–2893 | Cite as

Application of a simple, affordable quality metric tool to colorectal, upper gastrointestinal, hernia, and hepatobiliary surgery patients: the HARM score

  • Justin T. Brady
  • Bona Ko
  • Samuel F. Hohmann
  • Benjamin P. Crawshaw
  • Jennifer A. Leinicke
  • Scott R. Steele
  • Knut M. Augestad
  • Conor P. Delaney



Quality is the major driver for both clinical and financial assessment. There remains a need for simple, affordable, quality metric tools to evaluate patient outcomes, which led us to develop the HospitAl length of stay, Readmission and Mortality (HARM) score. We hypothesized that the HARM score would be a reliable tool to assess patient outcomes across various surgical specialties.


From 2011 to 2015, we identified colorectal, hepatobiliary, upper gastrointestinal, and hernia surgery admissions using the Vizient Clinical Database. Individual and hospital HARM scores were calculated from length of stay, 30-day readmission, and mortality rates. We evaluated the correlation of HARM scores with complication rates using the Clavien–Dindo classification.


We identified 525,083 surgical patients: 206,981 colorectal, 164,691 hepatobiliary, 97,157 hernia, and 56,254 upper gastrointestinal. Overall, 53.8% of patients were admitted electively with a mean HARM score of 2.24; 46.2% were admitted emergently with a mean HARM score of 1.45 (p < 0.0001). All HARM components correlated with patient complications on logistic regression (p < 0.0001). The mean length of stay increased from 3.2 ± 1.8 days for a HARM score < 2 to 15.1 ± 12.2 days for a HARM score > 4 (p < 0.001). In elective admissions, for HARM categories of < 2, 2–< 3, 3–4, and > 4, complication rates were 9.3, 23.2, 38.8, and 71.6%, respectively. There was a similar trend for increasing HARM score in emergent admissions as well. For all surgical procedure categories, increasing HARM score, with and without risk adjustment, correlated with increasing severity of complications by Clavien–Dindo classification.


The HARM score is an easy-to-use quality metric that correlates with increasing complication rates and complication severity across multiple surgical disciplines when evaluated on a large administrative database. This inexpensive tool could be adopted across multiple institutions to compare the quality of surgical care.


Surgical outcomes Quality Colorectal Hepatobiliary 



This study was supported by a SAGES Research Grant.

Author contributions

All authors made substantial contributions to conception and design, and/or acquisition of data, and/or analysis and interpretation of data; participated in drafting the article or revising it critically for important intellectual content and gave final approval of the version to be submitted and any revised version to be published.

Compliance with ethical standards


Dr. Samuel F. Hohmann is employed by Vizient as a Research Analytics Director, Dr. Scott R. Steele has consulted to Medtronic and Ethicon, Dr. Conor P. Delaney has consulted to Merck, Ethicon, Trans-Enterix and Recro-Pharma, Dr. Justin Brady, Dr. Bona Ko, Dr. Benjamin P. Crawshaw, Dr. Jennifer A. Leinicke, and Dr. Knut M. Augestad have no conflicts of interest or financial ties to disclose.

Supplementary material

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Supplementary material 1 (DOCX 12 KB)
464_2017_5998_MOESM2_ESM.docx (19 kb)
Supplementary material 2 (DOCX 19 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Authors and Affiliations

  • Justin T. Brady
    • 1
  • Bona Ko
    • 2
  • Samuel F. Hohmann
    • 3
    • 4
  • Benjamin P. Crawshaw
    • 1
  • Jennifer A. Leinicke
    • 1
  • Scott R. Steele
    • 5
  • Knut M. Augestad
    • 6
    • 7
  • Conor P. Delaney
    • 8
  1. 1.Division of Colorectal Surgery, Department of SurgeryUniversity Hospitals Cleveland Medical CenterClevelandUSA
  2. 2.Case Western Reserve University School of MedicineClevelandUSA
  3. 3.Center for Advanced Analytics, VizientChicagoUSA
  4. 4.Department of Health Systems ManagementRush UniversityChicagoUSA
  5. 5.Department of Colorectal SurgeryCleveland ClinicClevelandUSA
  6. 6.Department of Gastrointestinal SurgeryAkershus University HospitalOsloNorway
  7. 7.Department of Gastrointestinal SurgeryNordland Hospital TrustBodøNorway
  8. 8.Digestive Disease and Surgery InstituteCleveland ClinicClevelandUSA

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