Abstract
Introduction
Failure to rescue (FTR) (avoiding death after complications) has been proposed as
a measure of hospital quality. Although surviving complications is important, not
all rescues are created equal. Patients also place considerable values on being able
to return home after surgery and resume their normal lives. From a systems standpoint,
nonhome discharge to skilled nursing and other facilities is the biggest driver of
Medicare costs. We wanted to determine whether hospitals’ ability to keep patients
alive after complications was associated with higher rates of home discharge. We hypothesized
that hospitals with higher rescue rates would also be more likely to discharge patients
home after surgery.
Methods
We conducted a retrospective cohort study using the nationwide inpatient sample. We
included 1,358,041 patients ≥18 y old who had elective major surgery (general, vascular,
orthopedic) at 3818 hospitals from 2013 to 2017. We predicted the correlation between
a hospital's performance (rank) on FTR and its rank in terms of home discharge rate.
Results
The cohort had a median age of 66 y (interquartile range [IQR] 58-73), and 77.9% of
patients were Caucasian. Most patients (63.6%) were treated at urban teaching institutions.
The surgical case mix included patients having colorectal (146,993 patients; 10.8%),
pulmonary (52,334; 3.9%), pancreatic (13,635; 1.0%), hepatic (14,821; 1.1%), gastric
(9182; 0.7%), esophageal (4494; 0.3%), peripheral vascular bypass (29,196; 2.2%),
abdominal aneurysm repair (14,327; 1.1%), coronary artery bypass (61,976; 4.6%), hip
replacement (356,400; 26.2%), and knee replacement (654,857; 48.2%) operations. The
overall mortality was 0.3%, the average hospital complication rate was 15.9%, the
median hospital rescue rate was 99% (IQR 70%-100%), and the median hospital rate of
home discharge was 80% (IQR 74%-85%).There was a small but positive correlation between
hospitals’ performance on the FTR metric and the likelihood of home discharge after
surgery (r = 0.0453; P = 0.006). When considering hospital rates of discharge to home following a postoperative
complication, there was a similar correlation between rescue rates and probability
of home discharge (r = 0.0963; P < 0.001). However, on sensitivity analysis excluding orthopedic surgery, there was
a stronger correlation between rescue rates and home discharge rate (r = 0.4047, P < 0.001).
Conclusions
We found a small correlation between a hospital's ability to rescue patients from
complication and that hospital's likelihood of discharging patients home after surgery.
When excluding orthopedic operations from the analysis, this correlation strengthened.
Our findings suggest that efforts to reduce mortality after complications will likely
also help patients return home more frequently after complex surgery. However, more
work needs to be done to identify successful programs and other patient and hospital
factors that affect both rescue and home discharge.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Surgical ResearchAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Hospital and patient characteristics associated with death after surgery: a study of adverse occurrence and failure to rescue.Med Care. 1992; 30: 615-627
- Failure to rescue in surgical patients: a review for acute care surgeons.J Trauma Acute Care Surg. 2019; 87: 699-706
- Failure to rescue as a surgical quality indicator: current concepts and future directions for improving surgical outcomes.Anesthesiology. 2019; 131: 426-437
- Raising the bar for failure to rescue: critical appraisal of current measurement and strategies to catalyze improvement.JAMA Surg. 2015; 150: 1023-1024
- Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients.Ann Surg. 2009; 250: 1029-1034
- The relative importance of post-acute care and readmissions for post-discharge spending.Health Serv Res. 2016; 51: 1919-1938
- Hospitals using bundled payment report reducing skilled nursing facility use and improving care integration.Health Aff. 2018; 37: 1282-1289
- Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery.Surgery. 2019; 166: 1-7
- Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries.HPB. 2020; 22: 109-115
- Discharge disposition to skilled nursing facility after emergent general surgery predicts a poor prognosis.Surgery. 2019; 166: 489-495
- Association of high-volume hospitals with greater likelihood of discharge to home following colorectal surgery.JAMA Surg. 2014; 149: 244-251
- Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery.Br J Anaesth. 2017; 119: 258-266
- Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.Surgery. 2014; 155: 989-994
- Hospital volume and failure to rescue with high-risk surgery.Med Care. 2011; 49: 1076-1081
- Improving postoperative rescue through a multifaceted approach.Surg Clin North Am. 2021; 101: 71-80
- Impact of hospital characteristics on failure to rescue following major surgery.Ann Surg. 2016; 263: 692-697
- Improving mortality following emergent surgery in older patients requires focus on complication rescue.Ann Surg. 2013; 258: 614-617
- The effect of comprehensive society of thoracic surgeons quality improvement on outcomes and failure to rescue.Ann Thorac Surg. 2015; 100: 2147-2150
- Variation in surgical outcomes across networks of the highest-rated US hospitals.JAMA Surg. 2019; 154: 510-515
- A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.Surgery. 2015; 157: 752-763
- Failure-to-rescue in patients undergoing surgery for esophageal or gastric cancer.Eur J Surg Oncol. 2017; 43: 1962-1969
- Impact of hospital safety-net status on failure to rescue after major cardiac surgery.Surgery. 2019; 166: 778-784
- Failure to rescue after emergency general surgery in geriatric patients: does frailty matter?.J Surg Res. 2019; 233: 397-402
- Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery.JAMA Surg. 2018; 153: e180214
- Failure to rescue as a source of variation in hospital mortality after hepatic surgery.Br J Surg. 2014; 101: 836-846
- Failure-to-rescue rate as a measure of quality of care in a cardiac surgery recovery unit: a five-year study.Ann Thorac Surg. 2014; 97: 147-152
- Variation and impact of multiple complications on failure to rescue after inpatient surgery.Ann Surg. 2017; 266: 59-65
- Factors influencing failure to rescue after pancreaticoduodenectomy: a national surgical quality improvement project perspective.J Surg Res. 2017; 214: 131-139
- Complications and failure to rescue after inpatient noncardiac surgery in the veterans affairs health system.JAMA Surg. 2016; 151: 1157-1165
- Complications and failure to rescue following laparoscopic or open gastrectomy for gastric cancer: a propensity-matched analysis.Surg Endosc. 2017; 31: 2325-2337
- Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.JAMA Surg. 2014; 149: 229-235
- Home discharge has increased after total hip arthroplasty, however rates vary between large databases.J Arthroplasty. 2021; 36: 586-592.e1
- Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit.HPB. 2018; 20: 759-767
- Hospital variation in mortality after emergent bowel resections: the role of failure-to-rescue.J Trauma Acute Care Surg. 2018; 84: 702-710
- The impact of frailty on failure-to-rescue in geriatric trauma patients: a prospective study.J Trauma Acute Care Surg. 2016; 81: 1150-1155
- The quality of life of older people aging in place: a literature review.Qual Life Res. 2017; 26: 2899-2907
- Home, please: a conjoint analysis of patient preferences after a bad hip fracture.Geriatr Gerontol Int. 2015; 15: 1165-1170
- Quality of life related to fear of falling and hip fracture in older women: a time trade off study.BMJ. 2000; 320: 341-346
Article info
Publication history
Published online: March 07, 2023
Accepted:
January 21,
2023
Received in revised form:
December 14,
2022
Received:
March 1,
2022
Identification
Copyright
Published by Elsevier Inc.
