title: Comparing Preoperative Targets to Failure-to-Rescue for Surgical Mortality Improvement.
abstract: BACKGROUND
  Failure-to-rescue (FTR or death after postoperative complication) is thought to explain surgical mortality excesses across hospitals, and FTR is an emerging performance measure and target for quality improvement. We compared the FTR population to preoperatively identifiable subpopulations for their potential to close the mortality gap between lowest- and highest-mortality hospitals.
  
  
  METHODS
  Patients undergoing small bowel resection, pancreatectomy, colorectal resection, open abdominal aortic aneurysm repair, lower extremity arterial bypass, and nephrectomy were identified in the 2007 to 2011 Nationwide Inpatient Sample. Lowest- and highest-mortality hospitals were defined using risk- and reliability-adjusted mortality quintiles. Five target subpopulations were established a priori: the FTR population, predicted high-mortality risk (predicted highest-risk quintile), emergency surgery, elderly (>75 years old), and diabetic patients.
  
  
  RESULTS
  Across the lowest mortality quintile (n=282 hospitals, 56,893 patients) and highest-mortality quintile (282 hospitals, 45,784 patients), respectively, the size of target subpopulations varied only for the FTR population (20.2% vs 22.4%, p=0.002) but not for other subpopulations. Variation in mortality rates across lowest- and highest-mortality hospitals was greatest for the high-mortality risk (7.5% vs 20.2%, p<0.0001) and FTR subpopulations (7.8% vs 18.9%, p<0.0001). The FTR and high-risk populations had comparable sensitivity (81% and 75%) and positive predictive value (19% and 20%, respectively) for mortality. In Monte Carlo simulations, the mortality gap between the lowest- and highest-mortality hospitals was reduced by nearly 75% when targeting the FTR population or the high-risk population, 78% for the emergency surgery population, but less for elderly (51%) and diabetic (17%) populations.
  
  
  CONCLUSIONS
  Preoperatively identifiable patients with high estimated mortality risk may be preferable to the FTR population as a target for surgical mortality reduction.
authors: Department of Anesthesiology, Mayo Clinic, Rochester, MN; Center for Surgery and Public Health, Massachusetts General Hospital, Boston, MA. Electronic address: hyder.joseph@mayo.edu.
authors: Joseph A
authors: JA
authors: Hyder
authors: Center for Surgery and Public Health, Massachusetts General Hospital, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ONT, Canada.
authors: Elliot
authors: E
authors: Wakeam
authors: Center for Surgery and Public Health, Massachusetts General Hospital, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA.
authors: Joel T
authors: JT
authors: Adler
authors: Center for Surgery and Public Health, Massachusetts General Hospital, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA.
authors: Ann
authors: A
authors: DeBord Smith
authors: Divisions of General Internal Medicine and Sleep Medicine, Massachusetts General Hospital, Boston, MA; Brigham and Women's Hospital and Harvard Medical School, Massachusetts General Hospital, Boston, MA.
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Center for Surgery and Public Health, Massachusetts General Hospital, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA; Brigham and Women's Hospital and Harvard Medical School, Massachusetts General Hospital, Boston, MA.
authors: Louis L
authors: LL
authors: Nguyen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009010:Monte Carlo Method; D011183:Postoperative Complications / Q000401:mortality*; D057234:Preoperative Period; D058996:Quality Improvement; D012044:Regression Analysis; D015203:Reproducibility of Results; D020379:Risk Adjustment; D012680:Sensitivity and Specificity; D017211:Treatment Failure; D014481:United States / Q000453:epidemiology