Author(s): Ghaferi AA, Birkmeyer JD, Dimick JB, Ghaferi AA, Birkmeyer JD, Dimick JB
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Abstract 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.
This article was published in Ann Surg
and referenced in Journal of Surgery