Massarweh Nader N, Anaya Daniel A, Kougias Panagiotis, Bakaeen Faisal G, Awad Samir S, Berger David H
*VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX †Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX ‡Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL §Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH.
Ann Surg. 2017 Jul;266(1):59-65. doi: 10.1097/SLA.0000000000001917.
To examine the extent to which multiple, sequential complications impacts variation in institutional postoperative mortality rates.
Failure to rescue (FTR) has been proposed as an underlying factor in hospital variation in surgical mortality. However, little is currently known about hospital variation in FTR after multiple complications or the contribution of sequential complications to variation.
Retrospective cohort study of 266,101 patients within the Veterans Affairs Surgical Quality Improvement Program (2000-2014) who underwent a subset of high-mortality inpatient general, vascular, or thoracic procedures. The association between number of postoperative complications (0, 1, 2, or ≥3) and 30-day mortality across quintiles of hospital risk-adjusted mortality was evaluated with multivariable, multilevel mixed-effects models.
Among patients who had a complication, over half (60.9%) had 1, but those with more than 1 accounted for the majority of the deaths (63.1%). Across hospital quintiles, there were no differences in complications (23.5% very low mortality vs 23.6% very high mortality; trend test P = 0.15). FTR increased significantly (12.0% vs 18.1%; trend test P < 0.001) with an incremental impact as complications accrued (6.7% 1 complication vs 26.1% ≥3, lowest quintile; 11.7% 1 complication vs 33.0% ≥3, highest quintile). However, the risk of FTR associated with increasing complications remained relatively constant across hospital quintiles and was not explained by differences in patients presenting with multiple complications on the index complicated day.
FTR occurs predominantly among patients who have more than 1 complication with a dose-response relationship as complications accrue. As this dose-response relationship is observed across hospitals, surgical quality improvement efforts may benefit by shifting focus to broader interventions designed to prevent subsequent complications at all hospitals.
探讨多种连续并发症对机构术后死亡率差异的影响程度。
未能挽救（FTR）已被认为是医院手术死亡率差异的一个潜在因素。然而，目前对于多种并发症后FTR的医院差异或连续并发症对差异的贡献知之甚少。
对退伍军人事务部外科质量改进计划（2000 - 2014年）中266,101例接受高死亡率住院普通、血管或胸科手术子集的患者进行回顾性队列研究。采用多变量、多层次混合效应模型评估术后并发症数量（0、1、2或≥3）与医院风险调整死亡率五分位数中30天死亡率之间的关联。
在发生并发症的患者中，超过一半（60.9%）有1种并发症，但有多种并发症的患者占死亡总数的大部分（63.1%）。在医院五分位数中，并发症发生率无差异（极低死亡率组为23.5%，极高死亡率组为23.6%；趋势检验P = 0.15）。随着并发症的累积，FTR显著增加（12.0%对18.1%；趋势检验P < 0.001），且影响逐渐增大（最低五分位数组：1种并发症时为6.7%，≥3种并发症时为26.1%；最高五分位数组：1种并发症时为11.7%，≥3种并发症时为33.0%）。然而，与并发症增加相关的FTR风险在医院五分位数中保持相对恒定，且不能用指数并发症日出现多种并发症的患者差异来解释。
FTR主要发生在有多种并发症的患者中，且随着并发症的累积存在剂量反应关系。由于在各医院均观察到这种剂量反应关系，手术质量改进工作可能通过将重点转向旨在预防所有医院后续并发症的更广泛干预措施而受益。
