Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.

IMPORTANCE

To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality.

OBJECTIVE

To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications.

DESIGN, SETTING, AND PARTICIPANTS: We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile.

EXPOSURE

Hospital procedural volume.

MAIN OUTCOMES AND MEASURES

Hospital rates of risk-adjusted mortality, major complications, and failure to rescue.

RESULTS

For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred.

CONCLUSIONS AND RELEVANCE

High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.