title: Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients.
abstract: OBJECTIVE
  We sought to determine whether hospital variations in surgical mortality were due to differences in complication rates or failure to rescue rates (ie, case-fatality rates in patients with a complication).
  
  
  BACKGROUND
  Wide variations in mortality after major surgery are becoming increasingly apparent. The clinical mechanisms underling these variations are largely unexplored.
  
  
  METHODS
  We studied all Medicare beneficiaries undergoing 6 major operations in 2005 to 2006: pancreatectomy, esophagectomy, abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. We ranked hospitals according to risk-adjusted mortality and divided them into 5 equal groups. We then compared the incidence of complications and rates of failure to rescue between the top 20% of hospitals ("best") and bottom 20% of hospitals ("worst"). Analyses were conducted for all operations combined and for each individual procedure.
  
  
  RESULTS
  For all 6 operations combined, the worst hospitals had mortality rates 2.5-fold higher than the best hospitals (8.0% vs. 3.0%). However, complication rates were similar at worst and best hospitals (36.4% vs. 32.7%). In contrast, failure to rescue rates were much higher at the worst compared with the best hospitals (16.7% vs. 6.8%). These findings persisted in analyses with individual operations and specific complications.
  
  
  CONCLUSIONS
  Reducing variations in mortality will require strategies to improve the ability of high-mortality hospitals to manage postoperative complications.
authors: Department of Surgery, Michigan Surgical Collaborative for Outcomes Research and Evaluation (M-SCORE), University of Michigan, Ann Arbor, MI 48104, USA. aghaferi@umich.edu
authors: Amir A
authors: AA
authors: Ghaferi
authors: John D
authors: JD
authors: Birkmeyer
authors: Justin B
authors: JB
authors: Dimick
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007297:Inpatients; D008297:Male; D006278:Medicare; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000009:adverse effects*; D017211:Treatment Failure; D014481:United States / Q000453:epidemiology