Failure-to-Rescue as a Source of Variation in Hospital Mortality after Rectal Surgery: the Italian Experience

Abstract

Introduction: Failure to rescue (FTR) patients from postoperative complications could contribute to the variability in surgical mortality seen among hospitals with different volumes. We sought to examine the impact of complications and FTR on mortality following rectal surgery. Methods: The National Italian Hospital Discharge Dataset allowed to identify 75,280 patients who underwent rectal surgery between 2002 and 2014. Hospital volume was stratified into tertiles. Rates of major complications, FTR from complications and mortality following rectal surgery were compared. Results: During the study period, both the incidence of complications (2002, 23.7% versus 2014, 21.2%), and FTR decreased overtime (2002, 6.9% versus 2014, 3.8%) (both P < 0.001). The complication rate was 24.4% in low-, 21.6% in intermediate-and 20.4% in high-volume hospitals (P < 0.001). Complications were less common in minimally invasive surgery (MIS) versus open cases (18.2% versus 23.2%; P < 0.001). The most frequent complications included prolonged ileus or small bowel obstruction (5.3%), and anemia requiring blood transfusions (5.3%). The rate of FTR was 5.5%, 5.6% and 3.7% for low-, intermediate-and high-volume hospitals, respectively (P < 0.001). FTR after MIS was 2.6% vs. 5.5% after open surgery (P < 0.001). After accounting for patient and hospital characteristics, patients treated at low-volume hospitals were 23% more likely to die after a complication, compared to patients at high-volume hospitals (OR 1.23, 95%CI 1.13e1.33). Conclusions: Hospital volume is the strongest predictor of complication and FTR. The reduction in mortality in high-volume hospitals could be determined by the better ability to rescue patients. These findings support the centralization policy of rectal cancer treatment.

Safety-related outcomes of the Japanese Society of Hepato-Biliary-Pancreatic Surgery board certification system for expert surgeons

“…Although we have been able to decrease the mortality rate associated with high-level HBP surgeries overall, we believe that decreasing the mortality rates associated with left and right trisectionectomies, hepatectomy with biliary reconstruction, and PD in particular will be challenging. There are many reports stating that performance of surgery at high-volume centers results in improved mortality rates [18][19][20][21]. Judged by the numbers of HBP surgeries performed and the surgical safety records, our board-certified A and B training institutions actually function as highvolume centers.…”

ERAS: Improving outcome in the cachectic HPB patient

“…In this context, as mentioned earlier, it should be realized that morbidity rates may be similar in high-and low-volume centers, but mortality rates are far lower in high volume centers. 7 This relates to the failure to rescue concept, implying that once a complication occurs there is a risk of consecutive complications, 28 alternately leading to fatal outcomes. This is particularly true in the elderly and vulnerable patient such as those with cancer cachexia.…”