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Inpatient Postoperative Mortality: Comparing Patients Hospitalized Preoperatively to Those Having Elective Surgery
Richard H Epstein1, Franklin Dexter2, Brenda G Fahy3
1Department of Anesthesiology, Perioperative Medicine & Pain Management, University of Miami, Miller School of Medicine, Miami, Florida.
Insights
Most perioperative deaths occur in nonelective surgery patients, not elective ones. Focusing interventions on nonelective surgery cases, particularly inpatients, is crucial for reducing overall postoperative mortality.
Area of Science:
- Surgical outcomes research
- Public health policy
- Healthcare quality improvement
Background:
- Perioperative death is a leading global cause of mortality.
- Previous studies often did not differentiate between elective and nonelective surgery patients.
- Understanding mortality distribution is key to effective intervention strategies.
Purpose of the Study:
- To analyze perioperative mortality differences between elective and nonelective major surgery patients.
- To identify patient groups contributing most to overall perioperative deaths.
- To inform public health strategies for reducing surgical mortality.
Main Methods:
- Analysis of adult patients undergoing major surgery in Florida (2021-2022).
- Comparison of in-hospital survival rates between elective and nonelective surgical groups.
- Quantification of procedural diversity using ICD-10-PCS codes.
Main Results:
- Nonelective surgery accounted for 70% of hospitalizations and 94.5% of in-hospital deaths.
- The relative risk of death was significantly lower in the elective group (0.13).
- Hospital-acquired complications were less frequent in the elective group.
Conclusions:
- Most perioperative deaths occur in nonelective surgery patients.
- Previous studies on all-cause perioperative mortality may not be generalizable to elective surgery.
- Interventions should prioritize nonelective surgery patients, especially those already admitted.
Background:
Perioperative death globally has been described as the third leading cause of death behind heart disease and malignant neoplasm and ahead of cerebrovascular disease. However, studies of all-cause perioperative mortality have not distinguished patients who were outpatients preoperatively ("elective") from patients having urgent surgery or having surgery on a day after their date of admission ("nonelective"). Strategies for reducing overall perioperative mortality are affected by whether most deaths occur after elective or nonelective surgery.
Methods:
The authors studied all adult patients undergoing major diagnostic or therapeutic surgery in Florida in 2021 and 2022 hospitalized 2 or more midnights. They compared those who survived to discharge or died between the elective and nonelective groups. Major hospital-acquired complications were considered as sensitivity analyses. The diversity of procedures (International Classification of Diseases, Tenth Revision-Procedure Coding System [ICD-10-PCS] codes) was quantified using the inverse of the internal Herfindahl.
Results:
Among the 1,245,537 hospitalizations studied, the nonelective group accounted for 94.5% (95% CI, 94.0 to 95.1%) of the 20,874 in-hospital deaths ( P < 0.0001 vs. 50% ["most"]). The nonelective group also accounted for most (70.0%) hospitalizations studied. The relative risk of death in the elective versus nonelective group was 0.13 (95% CI, 0.12 to 0.14; P < 0.0001 vs . 1.0). The relative risks of acute kidney injury, hospital-acquired pneumonia, a major adverse cardiovascular event, and infection were all less than 1.0 in the elective group. Hundreds of different ICD-10-PCS codes occurred commonly among patients who died, in both groups.
Conclusions:
Results of previous studies of all-cause perioperative mortality should not be applied to patients having elective major surgery because most deaths (approximately 95%) and most cases (70%) are in patients having nonelective major surgery ( i.e. , already admitted to the hospital or undergoing trauma-related surgery). From a public health perspective, interventions to reduce postoperative mortality should be primarily focused on patients who are inpatients before their first major surgical procedure.
