Failure to rescue after proximal femur fracture surgery

Failure to rescue (FTR)--death after a major adverse event--has recently been identified as an important determinant of variation in surgical mortality. We sought to identify patient and hospital characteristics associated with FTR after proximal femur fracture surgery, and to determine whether they are different from the predictors of the occurrence of adverse events. We also identified which adverse events are most highly associated with FTR.

Among an estimated 287,959 patients with a surgically treated proximal femur fracture identified in the 2011 Nationwide Inpatient Sample, the overall adverse event rate was 22% and the FTR rate was 6.4%. Multivariable logistic regression modeling was used to identify independent predictors of FTR and adverse events.

Patient-specific variables influenced adverse event occurrence but exerted little or no influence on FTR. Hospitals located in rural areas were 14% less likely than urban hospitals to have adverse events [odds ratio (OR): 0.86, 95% confidence interval (CI): 0.83-0.89], but 30% more likely to fail to rescue patients from adverse events (OR: 1.3, 95% CI: 1.2-1.5). Compared with teaching and large hospitals, nonteaching settings and institutions of smaller size were associated with decreased risk for adverse events, but similar risk for FTR. Lower hospital volume was a risk factor for adverse events and FTR. There was a more than 3-fold increased risk for death among patients with respiratory failure (OR: 5.4, 95% CI: 5.0-5.8), pulmonary embolism (OR: 3.6, 95% CI: 3.1-4.1), and myocardial infarction (OR: 3.0, 95% CI: 2.8-3.3).

Because FTR is less affected by patient characteristics than morbidity, it might be a better measure of provider-specific performance in hip fracture surgery. Targeted initiatives aimed at improving the timely recognition and management of cardiorespiratory adverse events --particularly at rural hospitals--might be key to reducing mortality.

Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.