From the Department of Surgery, University of Michigan, Ann Arbor.
Ann Surg. 2013 Oct;258(4):614-7; discussion 617-8. doi: 10.1097/SLA.0b013e3182a5021d.
To determine whether a hospital's ability to rescue patients from major complications underlies variation in outcomes for elderly patients undergoing emergent surgery.
Perioperative mortality rates in elderly patients undergoing emergent general/vascular operations are high and vary widely across Michigan hospitals.
We identified 23,224 patients undergoing emergent general/vascular surgical procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2006 and 2011. Hospitals were ranked by risk- and reliability-adjusted 30-day mortality rates and grouped into tertiles. We stratified patients by age (<75 and ≥75 years). Risk-adjusted major complication and failure-to-rescue (ie, mortality after major complication) rates were determined for each tertile of hospital mortality.
Risk-adjusted mortality rates in elderly patients varied 2-fold across all hospitals. Complication rates correlated poorly with mortality. Failure-to-rescue rates, however, were markedly higher in high-mortality hospitals (29% lowest tertile vs 41% highest tertile; P < 0.01). When compared with younger patients, overall failure-to-rescue rates were almost 2-fold greater in the elderly (36.1% ≥75 vs 18.7% <75; P < 0.01).
A hospital's failure to rescue patients from major complications seems to underlie the variation in mortality rates across Michigan hospitals after emergent surgery. Although higher failure-to-rescue rates in the elderly may signify their diminished physiological reserve for surviving critical illness, the wide variation across hospitals also highlights the importance of systems aimed at the early recognition and effective management of major complications in this vulnerable population.
确定医院对患者进行重大并发症抢救的能力是否是导致老年急诊手术患者结局差异的原因。
接受紧急普通/血管手术的老年患者围手术期死亡率较高，且密歇根州各医院之间差异很大。
我们在 2006 年至 2011 年间，在密歇根手术质量协作组内的 41 家医院中确定了 23224 例接受紧急普通/血管手术的患者。根据风险和可靠性调整后的 30 天死亡率对医院进行排名，并将其分为三组。根据患者年龄（<75 岁和≥75 岁）对患者进行分层。确定了每个医院死亡率三分位组的风险调整后主要并发症和抢救失败（即重大并发症后的死亡率）率。
在所有医院中，老年患者的风险调整死亡率差异达 2 倍。并发症发生率与死亡率相关性较差。然而，在高死亡率医院中，抢救失败的发生率明显更高（最低三分位组为 29%，最高三分位组为 41%；P<0.01）。与年轻患者相比，老年患者的整体抢救失败率几乎高出 2 倍（≥75 岁为 36.1%，<75 岁为 18.7%；P<0.01）。
医院抢救重大并发症患者的能力似乎是密歇根州各医院急诊手术后死亡率差异的原因。尽管老年患者的抢救失败率较高可能意味着他们在应对重症疾病时的生理储备能力下降，但各医院之间的广泛差异也突出了针对这一脆弱人群的早期识别和有效管理重大并发症的系统的重要性。
