Is surgery getting safer? National trends in operative mortality.
BACKGROUND
Although mortality rates for some cardiovascular procedures seem to have declined, it is unclear whether other high-risk procedures are becoming safer over time.


METHODS
We examined national trends between 1994 and 1999 in operative mortality for 14 high-risk cardiovascular and cancer procedures in the national population of Medicare beneficiaries over age 65. Secular trends were examined using logistic regression adjusting for age, gender, race, socioeconomic status, admission acuity, comorbidities, and hospital volume.


RESULTS
Observed mortality rates varied widely across the 14 procedures, from 2% (carotid endarterectomy) to 16% (esophagectomy). Over the 6-year study period, average patient age increased for all procedures, and patients were more likely to undergo operation at high-volume hospitals for some procedures (pancreatic resection, esophagectomy, cystectomy, and pneumonectomy). After accounting for these changes, operative mortality declined significantly for three cardiovascular procedures, as evidenced by adjusted odds ratios (OR) for the 6-year effect on operative mortality (coronary artery bypass graft OR = 0.85, 95% confidence interval [CI] 0.81 to 0.88; carotid endarterectomy OR = 0.86,95% CI 0.80 to 0.93; mitral valve replacement OR = 0.89, 95% CI 0.81 to 0.97). In contrast, operative mortality did not decline for any of the cancer procedures. In fact, adjusted mortality increased for colectomy for colon cancer (OR= 1.13, 95% CI 1.07 to 1.19).


CONCLUSIONS
Although risks of some cardiovascular procedures are declining over time, there is no evidence that other types of high-risk surgery are becoming safer. These findings suggest the need for systematic efforts to monitor and improve surgical performance.
Goodney
Philip P
PP
VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA.
Siewers
Andrea E
AE
Stukel
Therese A
TA
Lucas
F Lee
FL
Wennberg
David E
DE
Birkmeyer
John D
JD
D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery; D016001:Confidence Intervals; D001026:Coronary Artery Bypass / Q000401:mortality; D016894:Endarterectomy, Carotid / Q000401:mortality; D016629:Esophagectomy / Q000401:mortality; D005743:Gastrectomy / Q000401:mortality; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery; D006801:Humans; D016015:Logistic Models; D006278:Medicare / Q000706:statistics & numerical data; D008943:Mitral Valve / Q000601:surgery; D009369:Neoplasms / Q000401:mortality; D016017:Odds Ratio; D013514:Surgical Procedures, Operative / Q000401:mortality*; D014656:Vascular Surgical Procedures / Q000401:mortality