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Comparative Study
. 2014 Feb;149(2):119-23.
doi: 10.1001/jamasurg.2013.3649.

Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue

Andrew A Gonzalez  1 , Justin B Dimick  2 , John D Birkmeyer  2 , Amir A Ghaferi  2
Affiliations
Comparative Study

Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue

Andrew A Gonzalez et al. JAMA Surg. 2014 Feb.

Abstract

Importance: To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality.

Objective: To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications.

Design, setting, and participants: We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile.

Exposure: Hospital procedural volume.

Main outcomes and measures: Hospital rates of risk-adjusted mortality, major complications, and failure to rescue.

Results: For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred.

Conclusions and relevance: High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.

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Figures

Figure 1
Figure 1
Hospital Rates of Risk-Adjusted Mortality, Major Complications, and Failure to Rescue.
See this image and copyright information in PMC

Comment in

  • Rescuing failures: can large data sets provide the answer?
    Kao LS. Kao LS. JAMA Surg. 2014 Feb;149(2):124. doi: 10.1001/jamasurg.2013.3674. JAMA Surg. 2014. PMID: 24337548 No abstract available.
  • Failure to rescue.
    Silber JH. Silber JH. JAMA Surg. 2014 Jul;149(7):747-8. doi: 10.1001/jamasurg.2014.589. JAMA Surg. 2014. PMID: 25029183 No abstract available.
  • Failure to rescue--reply.
    Ghaferi AA, Gonzalez AA. Ghaferi AA, et al. JAMA Surg. 2014 Jul;149(7):748-9. doi: 10.1001/jamasurg.2014.592. JAMA Surg. 2014. PMID: 25029184 No abstract available.

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