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Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients
Amir A Ghaferi1, John D Birkmeyer, Justin B Dimick
1Department of Surgery, Michigan Surgical Collaborative for Outcomes Research and Evaluation (M-SCORE), University of Michigan, Ann Arbor, MI 48104, USA. aghaferi@umich.edu
Objective:
We sought to determine whether hospital variations in surgical mortality were due to differences in complication rates or failure to rescue rates (ie, case-fatality rates in patients with a complication).
Background:
Wide variations in mortality after major surgery are becoming increasingly apparent. The clinical mechanisms underling these variations are largely unexplored.
Methods:
We studied all Medicare beneficiaries undergoing 6 major operations in 2005 to 2006: pancreatectomy, esophagectomy, abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. We ranked hospitals according to risk-adjusted mortality and divided them into 5 equal groups. We then compared the incidence of complications and rates of failure to rescue between the top 20% of hospitals ("best") and bottom 20% of hospitals ("worst"). Analyses were conducted for all operations combined and for each individual procedure.
Results:
For all 6 operations combined, the worst hospitals had mortality rates 2.5-fold higher than the best hospitals (8.0% vs. 3.0%). However, complication rates were similar at worst and best hospitals (36.4% vs. 32.7%). In contrast, failure to rescue rates were much higher at the worst compared with the best hospitals (16.7% vs. 6.8%). These findings persisted in analyses with individual operations and specific complications.
Conclusions:
Reducing variations in mortality will require strategies to improve the ability of high-mortality hospitals to manage postoperative complications.
Insights
Hospital variations in surgical mortality are not due to complication rates but failure to rescue. Improving care for patients with complications is key to reducing surgical mortality disparities.
Area of Science:
- Healthcare Quality
- Surgical Outcomes
- Hospital Performance
Background:
- Significant variations in surgical mortality exist across hospitals.
- The underlying causes of these mortality disparities remain largely unknown.
Purpose of the Study:
- To investigate whether hospital differences in surgical mortality stem from varying complication rates or differing abilities to manage complications (failure to rescue).
Main Methods:
- Analysis of Medicare beneficiaries undergoing six major surgeries (2005-2006).
- Hospitals ranked by risk-adjusted mortality and divided into quintiles.
- Comparison of complication and failure to rescue rates between top and bottom performing hospitals.
Main Results:
- Worst-performing hospitals had 2.5 times higher mortality than best-performing hospitals.
- Complication rates were similar between best and worst hospitals.
- Failure to rescue rates were substantially higher in worst-performing hospitals.
Conclusions:
- Strategies to reduce surgical mortality disparities must focus on enhancing the management of postoperative complications in lower-performing hospitals.
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