Objective: To elucidate clinical mechanisms underlying variation in hospital mortality after cancer surgery
Background: Thousands of Americans die every year undergoing elective cancer surgery. Wide variation in hospital mortality rates suggest opportunities for improvement, but these efforts are limited by uncertainty about why some hospitals have poorer outcomes than others.
Methods: Using data from the 2006–2007 National Cancer Data Base, we ranked 1279 hospitals according to a composite measure of perioperative mortality after operations for bladder, esophagus, colon, lung, pancreas, and stomach cancers. We then conducted detailed medical record review of 5632 patients at 1 of 19 hospitals with low mortality rates (2.1%) or 30 hospitals with high mortality rates (9.1%). Hierarchical logistic regression analyses were used to compare risk-adjusted complication incidence and case-fatality rates among patients experiencing serious complications.
Results: The 7.0% absolute mortality difference between the 2 hospital groups could be attributed to higher mortality from surgical site, pulmonary, thromboembolic, and other complications. The overall incidence of complications was not different between hospital groups [21.2% vs 17.8%; adjusted odds ratio (OR) = 1.34, 95% confidence interval (CI): 0.93–1.94]. In contrast, case-fatality after complications was more than threefold higher at high mortality hospitals than at low mortality hospitals (25.9% vs 13.6%; adjusted OR = 3.23, 95% CI: 1.56–6.69).
Conclusions: Low mortality and high mortality hospitals are distinguished less by their complication rates than by how frequently patients die after a complication. Strategies for ensuring the timely recognition and effective management of postoperative complications will be essential in reducing mortality after cancer surgery.
This is a national cohort study of cancer surgery at 49 very low or very high mortality hospitals. The overall incidence of complications was not different between hospital groups, but case-fatality after complications was more than threefold higher. These hospitals are distinguished less by their complication rates than by how frequently patients die after a complication (so-called “failure to rescue”).
*Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan Medical School, Ann Arbor
†Remedy Informatics, Chicago, IL; and
‡Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor.
Reprints: Sandra L. Wong, MD, MS, Center for Healthcare Outcomes and Policy, Building 16, 2800 Plymouth Road, Ann Arbor, MI 48109. E-mail: firstname.lastname@example.org.
Disclosures: This work was supported by the National Cancer Institute at the National Institutes of Health (2 R01 CA098481-05A1 to J.D.B.) and the Agency for Healthcare Research and Quality (K08 HS020937-01 to S.L.W.). J.D.B. has a financial interest in ArborMetrix, Inc, a clinical analytics company focused on hospital- and specialty-based care. The company was not involved with the study herein in any way. Other authors have no conflicts of interest.