Department of Surgery, Mayo Clinic, Rochester, Minnesota.
Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
Ann Thorac Surg. 2020 Mar;109(3):865-871. doi: 10.1016/j.athoracsur.2019.09.044. Epub 2019 Nov 9.
Data on failure to rescue (FTR) after esophagectomy are sparse. We sought to better understand the patient factors associated with FTR and to assess whether FTR is associated with hospital volume.
We identified all patients undergoing esophagectomy between 2010 and 2014 from the Agency for Healthcare Research and Quality Nationwide Readmission Database. We defined FTR as mortality after a major complication. Multiple logistic regression was used to identify patient factors and hospital-volume associations with FTR.
Of 26,820 patients undergoing an esophagectomy, 7130 (26.6%) experienced a major complication. Of those, 1321 did not survive the index hospitalization (FTR rate, 18.5%). Risk factors for FTR included increasing age (adjusted odds ratio [aOR], 1.06; P < .001), congestive heart failure (aOR, 2.07; P < .001), bleeding disorders (aOR, 2.9; P < .001), liver disease (aOR, 2.37; P = .001), and renal failure (aOR, 2.37; P = .002). At the hospital level there was wide variation in FTR rates across hospital volume quintiles, with 21.2% of patients suffering a complication not surviving to discharge at low-volume hospitals compared with 13.4% at high-volume hospitals (P < .001). At low-volume hospitals the highest FTR rates were acute renal failure (35.3%), postoperative hemorrhage (31.9%), and pulmonary failure (28.1%).
One in 5 esophagectomy patients suffering a complication at low-volume hospitals do not survive to discharge. Several patient factors are associated with death after a major complication. Strategies to improve the recognition and management of complications in at-risk patients may be essential to improve outcomes at low-volume hospitals.
关于食管癌手术后未能抢救（FTR）的数据很少。我们试图更好地了解与 FTR 相关的患者因素，并评估 FTR 是否与医院容量有关。
我们从美国医疗保健研究与质量国家再入院数据库中确定了 2010 年至 2014 年间所有接受食管癌手术的患者。我们将 FTR 定义为主要并发症后的死亡率。使用多因素逻辑回归分析确定与 FTR 相关的患者因素和医院容量。
在 26820 例接受食管癌手术的患者中，7130 例（26.6%）发生了主要并发症。其中，1321 例患者在指数住院期间未存活（FTR 发生率为 18.5%）。FTR 的危险因素包括年龄增加（调整后的优势比[aOR]，1.06；P<0.001）、充血性心力衰竭（aOR，2.07；P<0.001）、出血性疾病（aOR，2.9；P<0.001）、肝脏疾病（aOR，2.37；P=0.001）和肾衰竭（aOR，2.37；P=0.002）。在医院层面，医院容量五分位法中 FTR 率差异很大，低容量医院发生并发症的患者中有 21.2%未存活到出院，而高容量医院这一比例为 13.4%（P<0.001）。在低容量医院，FTR 率最高的是急性肾衰竭（35.3%）、术后出血（31.9%）和肺衰竭（28.1%）。
在低容量医院接受食管癌手术的患者中，每 5 例发生并发症的患者中就有 1 例未存活到出院。一些患者因素与主要并发症后的死亡有关。改善高危患者对并发症的识别和管理的策略可能对提高低容量医院的疗效至关重要。
