Variation in postoperative complication rates after high-risk surgery in the United States.
OBJECTIVE
Our goal was to characterize variation in complication rates across hospitals with differing volumes for select high-risk operations in the United States.


METHODS
Data from the Nationwide Inpatient Sample for 1996 and 1997 were analyzed for 3 high-risk operations: esophagectomy (n=1,226), pancreatectomy (n=4,789), and intact abdominal aortic aneurysm repair (n=11,863). Complications evaluated included aspiration, cardiac complications, infection, pneumonia, pulmonary failure, renal failure, septicemia, and others. The risk of complications was calculated by hospital volume deciles, as well as for high-volume hospitals (HVH) and low-volume hospitals (LVH) defined by median hospital volume.


RESULTS
Rates of any postoperative complication varied nearly 2-fold across hospital volume groups. The proportion of patients across hospital deciles having at least one complication ranged from 30% to 51% for esophageal resection, 6% to 12% for pancreatic resection, and 9% to 18% for abdominal aortic aneurysm repair. HVH had lower rates of one or more complications after pancreatic resection (OR, 0.71; 95% CI, 0.57 to 0.83; P=.002), esophageal resection (OR, 0.68; 95% CI, 0.52 to 0.90; P=.008), and intact abdominal aortic aneurysm (AAA) repair (OR, 0.67; 95% CI, 0.59 to 0.76; P<.001). Patients with one or more complications after pancreatic resection had a mortality of 18.8% versus only 5.2% for those without complications (P<.001). Esophageal resection mortality was 16.9% for patients with at least one complication and 2.5% for those without complications (P<.001) and AAA repair mortality was 10.4% for patients with at least one complication and 2.9% for those without complications (P<.001).


CONCLUSIONS
High-risk operations have a decreased rate of postoperative complications when performed at HVH. Variation in complication rates may contribute to the volume-outcome relationship and provide a focus for quality improvement at LVH.
Dimick
Justin B
JB
Department of Surgery, University of Michigan Medical School, Taubman Center 2210, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0329, USA.
Pronovost
Peter J
PJ
Cowan
John A
JA
Lipsett
Pamela A
PA
Stanley
James C
JC
Upchurch
Gilbert R
GR
D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality; D018570:Risk Assessment; D013514:Surgical Procedures, Operative / Q000009:adverse effects*; D014481:United States / Q000453:epidemiology