title: Hospital-level Variation in Secondary Complications After Surgery.
abstract: OBJECTIVE
  To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality.
  
  
  BACKGROUND
  Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or "index" complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails.
  
  
  METHODS
  We used American College of Surgeons' National Surgical Quality Improvement Program data (2008-2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk- and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality.
  
  
  RESULTS
  A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95-5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41-9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48-9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31-2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20-9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6-2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80-3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26-6.81).
  
  
  CONCLUSIONS
  Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.
authors: *Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA †Department of Surgery, University of Toronto, Toronto, Canada ‡Department of Anesthesiology, Mayo Clinic, Rochester, MN §Division of Research/Optimal Patient Care, American College of Surgeons, Chicago, IL ||Department of Surgery, University of California-Los Angeles, Los Angeles, CA ¶Washington University in Saint Louis, Department of Surgery (School of Medicine), Olin Business School, and Center for Health Policy; BJC Healthcare St Louis, MO **Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT.
authors: Elliot
authors: E
authors: Wakeam
authors: Joseph A
authors: JA
authors: Hyder
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Mark E
authors: ME
authors: Cohen
authors: Dennis P
authors: DP
authors: Orgill
authors: Michael J
authors: MJ
authors: Zinner
authors: Cliff Y
authors: CY
authors: Ko
authors: Bruce L
authors: BL
authors: Hall
authors: Samuel R G
authors: SR
authors: Finlayson
mesh_terms: D019985:Benchmarking; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality; D011014:Pneumonia / Q000453:epidemiology / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality; D058996:Quality Improvement; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000401:mortality; D014552:Urinary Tract Infections / Q000453:epidemiology / Q000401:mortality