title: Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.
abstract: OBJECTIVE
  Failure to rescue (FTR), the mortality rate among surgical patients with complications, is an emerging quality indicator. Hospitals with a high safety-net burden, defined as the proportion of patients covered by Medicaid or uninsured, provide a disproportionate share of medical care to vulnerable populations. Given the financial strains on hospitals with a high safety-net burden, availability of clinical resources may have a role in outcome disparities.
  
  
  OBJECTIVE
  To assess the association between safety-net burden and FTR and to evaluate the effect of clinical resources on this relationship.
  
  
  METHODS
  A retrospective cohort of 46,519 patients who underwent high-risk inpatient surgery between January 1, 2007, and December 31, 2010, was assembled using the Nationwide Inpatient Sample. Hospitals were divided into the following 3 safety-net categories: high-burden hospitals (HBHs), moderate-burden hospitals (MBHs), and low-burden hospitals (LBHs). Bivariate and multivariate analyses controlling for patient, procedural, and hospital characteristics, as well as clinical resources, were used to evaluate the relationship between safety-net burden and FTR.
  
  
  METHODS
  FTR.
  
  
  RESULTS
  Patients in HBHs were younger (mean age, 65.2 vs 68.2 years; P = .001), more likely to be of black race (11.3% vs 4.2%, P < .001), and less likely to undergo an elective procedure (39.3% vs 48.6%, P = .002) compared with patients in LBHs. The HBHs were more likely to be large, major teaching facilities and to have high levels of technology (8.6% vs 4.0%, P = .02), sophisticated internal medicine (7.7% vs 4.3%, P = .10), and high ratios of respiratory therapists to beds (39.7% vs 21.1%, P < .001). However, HBHs had lower proportions of registered nurses (27.9% vs 38.8%, P = .02) and were less likely to have a positron emission tomographic scanner (15.4% vs 22.0%, P = .03) and a fully implemented electronic medical record (12.6% vs 17.8%, P = .03). Multivariate analyses showed that HBHs (adjusted odds ratio, 1.35; 95% CI, 1.19-1.53; P < .001) and MBHs (adjusted odds ratio, 1.15; 95% CI, 1.05-1.27; P = .005) were associated with higher odds of FTR compared with LBHs, even after adjustment for clinical resources.
  
  
  CONCLUSIONS
  Despite access to resources that can improve patient rescue rates, HBHs had higher odds of FTR, suggesting that availability of hospital clinical resources alone does not explain increased FTR rates.
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts2Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
authors.forename: Elliot
authors.initials: E
authors.lastname: Wakeam
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Nathanael D
authors.initials: ND
authors.lastname: Hevelone
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Maine
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Jabaris
authors.initials: J
authors.lastname: Swain
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stuart A
authors.initials: SA
authors.lastname: Lipsitz
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Samuel R G
authors.initials: SR
authors.lastname: Finlayson
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stanley W
authors.initials: SW
authors.lastname: Ashley
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts3Patient-Centered Comparative Effectiveness Research Center, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Joel S
authors.initials: JS
authors.lastname: Weissman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000401:mortality*; D019984:Quality Indicators, Health Care; D040841:Resource Allocation; D064876:Safety-net Providers / Q000592:standards / Q000706:statistics & numerical data*; D013514:Surgical Procedures, Operative / Q000401:mortality*