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Ten-year Trends in Surgical Mortality, Complications, and Failure to Rescue in Medicare Beneficiaries

Fry, Brian T. MS*,†; Smith, Margaret E. MD, MS*,‡; Thumma, Jyothi R. MPH*; Ghaferi, Amir A. MD, MS*,‡; Dimick, Justin B. MD, MPH*,‡

doi: 10.1097/SLA.0000000000003193
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Mini This study examines how reductions in postoperative complications and improvements in failure to rescue have contributed to improvements in surgical mortality over the past decade. Improvements in rescue explained the majority of observed improvements in surgical mortality, whereas decreased complication rates explained a small proportion of this improvement.

Objective: To evaluate how changes in complication and failure to rescue rates influence hospitals’ postoperative mortality rates.

Summary Background Data: Surgical mortality has declined over the last decade, but the mechanisms underlying these improvements are unknown. Specifically, the relative impact of reducing postoperative complications versus improving “failure to rescue” remains unclear.

Methods: Using Medicare claims data, we performed a retrospective study of abdominal aortic aneurysm repair, pulmonary resection, colectomy, and pancreatectomy patients. We examined risk-adjusted 30-day mortality, serious complications, and failure to rescue for these patients in from 2005 to 2014 (n = 702,268 patients in 3404 hospitals). Hospitals were then stratified into quintiles by their change in mortality over time.

Results: After stratifying by reductions in mortality from 2005 to 2014, the top 20% of hospitals decreased mortality by 37% (9.0%–5.7%, P < 0.001), decreased serious complications by 11% (15.2%–13.5%, P < 0.001), and decreased failure to rescue by 25% (25.2%–18.9%, P < 0.001). In contrast, the bottom 20% of hospitals increased mortality by 12% (6.9%–7.7%, P < 0.001), increased serious complications by 5% (14.6%–15.4%, P < 0.001), and increased failure to rescue by 4% (21.5%–22.3%, P < 0.001). Partitioning of variance demonstrated that decreased failure to rescue explained 64% of improvement in hospitals’ mortality over time, whereas decreased serious complications accounted for only 5% of this improvement.

Conclusions: Hospitals with the largest reductions in surgical mortality achieved these improvements primarily through reducing failure to rescue rates and not by reducing serious complication rates. This suggests that hospitals aiming to reduce surgical mortality should engage in efforts focused on improving rescue.

*University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, MI

University of Michigan Medical School, Ann Arbor, MI

University of Michigan Department of Surgery, Ann Arbor, MI.

Reprints: Brian T. Fry, MS, Center for Healthcare Outcomes and Policy, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109. E-mail: brianfry@med.umich.edu.

J.B.D. receives grant funding from the National Institutes of Health, the Agency for Healthcare Research and Quality, and is a cofounder of ArborMetrix, Inc, a company that makes software for profiling hospital quality and efficiency. The company had no role in the study herein. A.A.G. is supported through grants from the Agency for Healthcare Research and Quality and a Patient Centered Outcomes Research Institute Award. B.T.F. is supported by National Institutes of Health grant 1TL1TR002242 through the Master of Science in Clinical Research program at the University of Michigan. J.R.T. and B.T.F. had access to all of the data in this study and take full responsibility for the integrity of the data as well as the accuracy of the data analysis.

The authors report no conflicts of interest.

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