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Hospital variation in mortality after emergent bowel resections

The role of failure-to-rescue

Mehta, Ambar, MPH; Efron, David T., MD; Stevens, Kent, MD; Manukyan, Mariuxi C., MD; Joseph, Bellal, MD; Sakran, Joseph V., MD

Journal of Trauma and Acute Care Surgery: May 2018 - Volume 84 - Issue 5 - p 702–710
doi: 10.1097/TA.0000000000001827
AAST 2017 Podium Paper
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BACKGROUND Hospital variation in failure-to-rescue (FTR) rates has partially explained nationwide differences in mortality after elective surgeries. To examine the role of FTR among emergency general surgery, we compared nationwide risk-adjusted mortality, complications, and FTR rates after emergent bowel resections.

METHODS We identified patients who underwent emergent small or large bowel resections in the 2010 to 2011 Nationwide Inpatient Sample using the American Association for the Surgery of Trauma criteria. We then calculated risk-adjusted mortality rates for each hospital using multivariable logistic regressions and postestimation, which adjusted for patient age, sex, race and ethnicity, payer status, comorbidities, and hospital clustering. After excluding hospitals with fewer than 10 resections per year, we ranked the remaining hospitals by their risk-adjusted mortality rates and divided them into five quintiles. We compared both risk-adjusted complication rates and FTR rates between the top (lowest mortality) and bottom (highest mortality) quintiles.

RESULTS We identified 21,564 emergent bowel resections, weighted to 105,925 procedures nationwide. The bottom quintile of hospitals had an overall risk-adjusted mortality rate that was 10.9 times higher than that of the top quintile of hospitals (15.3% vs. 1.4%). While risk-adjusted complication rates were similarly high for both the bottom and the top quintiles of hospitals (22.5% vs. 15.7%), the risk-adjusted FTR rates were 10.8 times higher in the bottom quintile of hospitals relative to the top quintile of hospitals (33.4% vs. 3.1%). Using larger hospital volume thresholds yielded similar findings. Furthermore, large variations existed in complication-specific FTR rates (surgical site infection [6.6%] to myocardial infarction [29.4%]).

CONCLUSION Nationwide hospital variation in risk-adjusted mortality rates exist after emergent bowel resections. As complication rates were similar across hospitals, the significantly higher FTR rates at higher-mortality hospitals may drive this variation in mortality. System-level initiatives addressing the management of postoperative complications may improve patient care and reduce variation in outcomes.

LEVEL OF EVIDENCE Prognostic and epidemiological study, level IV.

From the Johns Hopkins, School of Medicine (A.M.); Department of Surgery (D.E., K.S., M.C.M., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; and Department of Surgery(B.J.), College of Medicine Tucson, University of Arizona, Tucson, Arizona.

Submitted: September 1, 2017, Revised: January 18, 2018, Accepted: January 22, 2018, Published online: February 3, 2018.

Address for reprints: Joseph V. Sakran, MD, MPH, MPA, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 6107 Baltimore, MD 21287; email: jsakran1@jhmi.edu.

Presentation: Plenary presentation at the 76th Annual Meeting of the American Association for the Surgery of Trauma, September 13–16, 2017, in Baltimore, MD.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

© 2018 Lippincott Williams & Wilkins, Inc.