title: Failure to rescue and mortality following repair of abdominal aortic aneurysm.
abstract: OBJECTIVE
  Recently, failure to rescue (FTR; death following major complication) has been shown to be a primary driver of mortality in highly morbid operations. Establishing this relationship for open and endovascular repair of abdominal aortic aneurysms may be a critical first step in improving mortality following these procedures. We sought to examine the relative contribution of severe complications and FTR to variations in mortality rate.
  
  
  METHODS
  We examined endovascular aortic repair (EVAR) and open aortic repair (OAR; n = 3215) performed in 40 hospitals participating in the Michigan Surgical Quality Collaborative from 2007 to 2012. Hospitals were first divided into risk-adjusted mortality tertiles. We then determined rates of severe complications and FTR within each tertile.
  
  
  RESULTS
  For EVAR, risk-adjusted hospital mortality rates varied significantly between the lowest and highest tertiles (0.07% vs 6.14%; P < .01). However, while major complication rates were almost identical (9.0 vs 9.8; P = NS), FTR rates were about 35 times greater in high-mortality hospitals (4.0% vs 33.3%). Similar associations with mortality, severe complications, and FTR were seen for OAR as well. The most common complications that led to FTR events were postoperative transfusion (OAR 29.8% vs EVAR 5.8%) and prolonged ventilation (OAR 18.2% vs EVAR 1.0%). The average number of severe complications per FTR event was 2.85 and 2.66 for OAR and EVAR, respectively.
  
  
  CONCLUSIONS
  FTR appears to drive a large proportion of the variation in mortality associated with abdominal aortic aneurysm repair. The exact mechanisms underlying this variation remain unknown. Nonetheless, FTR is influenced by the structural characteristics and safety culture related to the timely recognition and management of severe complications. Hospitals that are unable to effectively handle severe complications following EVAR or OAR require close scrutiny.
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Seth A
authors.initials: SA
authors.lastname: Waits
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Kyle H
authors.initials: KH
authors.lastname: Sheetz
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Darrell A
authors.initials: DA
authors.lastname: Campbell
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Amir A
authors.initials: AA
authors.lastname: Ghaferi
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Englesbe
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Eliason
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Mich. Electronic address: henke@umich.edu.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Henke
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality* / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D015994:Incidence; D008297:Male; D008824:Michigan / Q000453:epidemiology; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D012042:Registries; D012307:Risk Factors; D017211:Treatment Failure