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Inpatient Surgery and In-Hospital Mortality

Hospitals with low and high perioperative death rates have surprisingly similar rates of perioperative complications, which suggests that "failure to rescue" is the primary determinant of in-hospital mortality.

Mortality associated with inpatient surgery varies widely in the U.S. Although thorough preoperative risk assessment can help minimize surgical complications, discrepancies exist in how hospitals recognize and respond when major perioperative complications arise.

Researchers evaluated data from the American College of Surgeons National Surgical Quality Improvement Program on 84,730 patients who had undergone general or vascular surgical procedures at more than 150 hospitals. The analysis was restricted to inpatient procedures with mortality rates >1%. Risk-adjusted death rates varied widely among hospitals — from 3.5% to 6.9%. High-mortality and low-mortality hospitals had similar mixes of procedures (e.g., colectomy, gastrectomy, abdominal aortic aneurysm repair) and coexisting patient conditions. Rates for all complications and for major complications did not vary significantly among hospitals; however, death rates among patients with major complications were almost twice as high in hospitals with the highest overall mortality than in hospitals with the lowest overall mortality (21.4% vs. 12.5%).

Comment: As the authors note, ability to rescue a patient from a postoperative complication relies on timely recognition and effective management of that complication. Although quality nursing care, high nurse-to-patient ratios, and the presence of intensivists are factors that can contribute to better outcomes at very low–mortality hospitals, an unmeasured but valuable contributor also could be hospitalist comanagement of surgical patients. As an active presence at the bedside, hospitalists are uniquely positioned to recognize complications and intervene promptly. Although avoiding postoperative complications is crucial in lowering perioperative mortality, this study shows that the care patients receive when complications occur is just as important.

— Neil H. Winawer, MD, FHM

Published in Journal Watch Hospital Medicine September 30, 2009

Citation(s):

Ghaferi AA et al. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009 Oct 1; 361:1368.

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• Medline abstract (Free)

Jacobs DO. Variation in hospital mortality associated with inpatient surgery — An S.O.S. N Engl J Med 2009 Oct 1; 361:1398.

• Original article (Subscription may be required)
• Medline abstract (Free)