Balian Jeffrey, Cho Nam Yong, Vadlakonda Amulya, Kwon Oh Jin, Porter Giselle, Mallick Saad, Benharash Peyman
Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
Surg Open Sci. 2024 May 31;20:77-81. doi: 10.1016/j.sopen.2024.05.013. eCollection 2024 Aug.
Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event.
All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR.
Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI.
Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.
未能成功救治（FTR）日益被视为一项质量指标，但在急诊普通外科（EGS）中仍研究不足。我们试图确定与FTR相关的患者和手术因素，以便更好地为标准化指标提供信息，以减轻这一潜在可预防事件。
在2016 - 2020年国家再入院数据库中识别所有成年（≥18岁）因大肠切除术、小肠切除术、穿孔性溃疡修复术、剖腹术和粘连松解术而进行的非选择性住院治疗。入院≤2天接受与创伤相关手术或操作的患者被排除。FTR被定义为在急性肾损伤需要透析（AKI）、心肌梗死、肺炎、呼吸衰竭、败血症、中风或血栓栓塞后住院死亡。开发了多级混合效应模型来评估与FTR相关的因素。
在826,548例符合纳入标准的EGS手术中，298,062例（36.1%）发生了至少一种主要不良事件（MAE）。在发生MAE的患者中，43,477例（14.6%）最终未能存活至出院（FTR）。在对固定的医院层面效应进行调整后，FTR中仅有3.5%的方差可归因于中心层面的差异。相对于私人保险和最高收入四分位数，医疗补助保险（调整后比值比[AOR] 1.33；95%置信区间[CI]，1.23 - 1.43）和最低收入四分位数（AOR 1.22；95%CI，1.17 - 1.29）与FTR几率增加相关。一项亚组分析按保险状况对特定并发症的FTR发生率进行分层。相对于私人保险，医疗补助覆盖和未参保状态与围手术期败血症、肺炎和AKI后的FTR几率更高相关。
我们的研究结果强调，在围手术期并发症后需要加强筛查和警惕，以减轻高危EGS患者结局的差异。
