title: Failure to Rescue as a Quality Improvement Approach in Transplantation: A First Effort to Evaluate This Tool in Pediatric Liver Transplantation.
abstract: BACKGROUND
  Significant intercenter variation exists in mortality and death-censored graft loss (DCGL) after transplantation. Failure to rescue (FTR, death after a major complication) is an emerging tool in quality improvement and may underlie this variation. This study is the first effort to investigate the relationship between FTR and outcomes in transplantation to assess its utility in care improvement.
  
  
  METHODS
  Using the Studies of Pediatric Liver Transplantation database, we identified 2330 children undergoing primary liver transplants at 21 centers. Centers were ranked by risk-adjusted mortality and sorted into tertiles. We then compared mortality, complications, and FTR across tertiles.
  
  
  RESULTS
  Overall mortality was 4.9%, ranging from 1.4% to 8.1% in the low and high mortality tertiles (P < 0.01). The low mortality tertile had significantly lower rates of complications (30.9% vs 38.5% and 40.4%, P < 0.01) as well as FTR (4.6% vs 9.9% and 14.3%, P < 0.01). A similar trend was seen in the DCGL analysis.
  
  
  CONCLUSIONS
  Our results demonstrate that although centers with higher mortality and DCGL have more frequent major complications, they exhibit 3-fold the rate of FTR. Efforts to standardize perioperative care, and thus minimize FTR, will have value to pediatric liver transplantation recipients. This preliminary study indicates that FTR may provide a useful quality improvement tool for the field of transplantation and warrants further investigation.
authors.affiliation: 1 Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI. 2 Pediatric Liver Care Center, Cincinnati Children's Hospital, Cincinnati, OH. 3 Division of Gastroenterology, Seattle Children's Hospital, Seattle, WA. 4 Department of Surgery, University of Pittsburgh, Pittsburgh, PA. 5 The EMMES Corporation, Rockville, MD.
authors.forename: Shannon L
authors.initials: SL
authors.lastname: Cramm
authors.forename: Seth A
authors.initials: SA
authors.lastname: Waits
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Englesbe
authors.forename: John C
authors.initials: JC
authors.lastname: Bucuvalas
authors.forename: Simon P
authors.initials: SP
authors.lastname: Horslen
authors.forename: George V
authors.initials: GV
authors.lastname: Mazariegos
authors.forename: Kyle A
authors.initials: KA
authors.lastname: Soltys
authors.forename: Ravinder
authors.initials: R
authors.lastname: Anand
authors.forename: John C
authors.initials: JC
authors.lastname: Magee
mesh_terms: D000367:Age Factors; D002170:Canada; D002648:Child; D002675:Child, Preschool; D000067248:Failure to Rescue, Health Care; D005260:Female; D054625:Healthcare Disparities / Q000592:standards / Q000639:trends; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality* / Q000592:standards / Q000639:trends; D008137:Longitudinal Studies; D008297:Male; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D017064:Process Assessment, Health Care / Q000592:standards / Q000639:trends; D011446:Prospective Studies; D058996:Quality Improvement / Q000592:standards / Q000639:trends; D019984:Quality Indicators, Health Care / Q000592:standards / Q000639:trends; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014481:United States