Strengths and Limitations
The strengths of our study include the use of two high-volume statewide
databases, which capture a very large number of surgeons relative to
many other studies that have investigated this relationship.
Additionally, our dataset is comprised of two mandatory statewide
outcome reporting systems, which minimize potential selection bias or a
narrow scope of payer-specific databases such as Medicare data. A
limitation of our dataset is that while EMR is a strong measure of high
vs low risk patients, it does not necessarily reflect information about
case complexity or whether a case is elective vs nonelective, which will
be an important area for future investigation. Differences in the
California and New York risk models is another limitation of our dataset
– though these differences should be adequately adjusted for by
normalizing EMR by respective state mortality averages.