Complications, Failure to Rescue, and Mortality With Major Inpatient Surgery in Medicare Patients
Complications, Failure to Rescue, and Mortality With Major Inpatient Surgery in Medicare Patients
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DOI：
10.1097/sla.0b013e3181bef697
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发表时间：
2009-12-01
影响因子：
9
通讯作者：
Dimick, Justin B.
中科院分区：
文献类型：
--
作者：
Ghaferi, Amir A.;Birkmeyer, John D.;Dimick, Justin B.
目的：我们试图确定医院手术死亡率的差异是否是由于并发症发生率或抢救失败率（即并发症患者的病死率）的差异。背景：大手术后死亡率的广泛差异越来越明显。这些变化背后的临床机制在很大程度上unexplored.Methods：我们研究了所有医疗保险受益人在2005年至2006年进行6大手术：胰腺切除术，食管切除术，腹主动脉瘤修复术，冠状动脉旁路移植术，主动脉瓣置换术，二尖瓣置换术。我们根据风险调整后的死亡率对医院进行了排名，并将它们分为5个相等的组。然后，我们比较了前20%的医院（“最好”）和后20%的医院（“最差”）之间的并发症发生率和抢救失败率。对所有手术合并和每个单独的procedure.Results进行分析：对于所有6个手术合并，最差的医院的死亡率比最好的医院高2.5倍（8.0%比3.0%）。然而，最差和最好医院的并发症发生率相似（36.4% vs. 32.7%）。相比之下，最差医院的抢救失败率远高于最好医院（16.7%对6.8%）。这些研究结果坚持与个别操作和特定的complications.Conclusions分析：减少死亡率的变化将需要战略，以提高高死亡率的医院管理术后并发症的能力。
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.