Department of Surgery, Michigan Surgical Collaborative for Outcomes Research and Evaluation (M-SCORE), University of Michigan, Ann Arbor, MI 48104, USA.
Ann Surg. 2009 Dec;250(6):1029-34. doi: 10.1097/sla.0b013e3181bef697.
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).
Wide variations in mortality after major surgery are becoming increasingly apparent. The clinical mechanisms underling these variations are largely unexplored.
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.
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.
Reducing variations in mortality will require strategies to improve the ability of high-mortality hospitals to manage postoperative complications.
我们旨在确定医院手术死亡率的差异是否归因于并发症发生率或未能抢救率（即伴有并发症患者的病死率）的差异。
主要手术后死亡率的广泛差异日益明显。这些差异的临床机制在很大程度上尚未得到探索。
我们研究了 2005 年至 2006 年期间接受 6 种主要手术的所有 Medicare 受益人的数据：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、主动脉瓣置换术和二尖瓣置换术。我们根据风险调整死亡率对医院进行排名，并将它们分为 5 个相等的组。然后，我们比较了前 20%的医院（“最佳”）和后 20%的医院（“最差”）并发症发生率和未能抢救的比率。对所有手术和每个单独的手术都进行了分析。
对于所有 6 种手术的组合，最差的医院死亡率比最好的医院高 2.5 倍（8.0%对 3.0%）。然而，最差和最好医院的并发症发生率相似（36.4%对 32.7%）。相比之下，最差医院的未能抢救率比最好医院高得多（16.7%对 6.8%）。这些发现存在于对个别手术和特定并发症的分析中。
降低死亡率的差异将需要制定策略，以提高高死亡率医院管理术后并发症的能力。
