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Response to Commentaries on Silber et al.: Aggressive Treatment Styles and Surgical Outcomes

We thank Amber Barnato (Barnato 2010), and Elliot Fisher and Jonathan Skinner (Fisher and Skinner 2010) for their thoughtful comments on our paper (Silber et al. 2010).

Common themes discussed by Barnato, and Fisher and Skinner concerned the use of 30-day versus 365-day mortality and the effect size associated with aggressiveness. We believe it is appropriate to focus on results from the analysis of 30-day mortality and not 365-day mortality, as do Barnato, and Fisher and Skinner when they interpret our findings. An important reason for our preference is that the 30-day window is most closely aligned to the research question of interest, which is to assess how differences in hospital treatment styles, as measured by Dartmouth end-of-life measures, affect surgical quality (see equation 2 in our paper [Silber et al. 2010]). Examining a period beyond 30 days increases the likelihood that the association between aggressiveness and surgical outcomes will be confounded by effects on survival of treatment by other providers.

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