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1.
J Surg Res ; 245: 629-635, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31522036

RESUMEN

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Asunto(s)
Tratamiento de Urgencia/efectos adversos , Disparidades en Atención de Salud/economía , Renta/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Adolescente , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Pacientes Internos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Población Rural/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricos , Adulto Joven
2.
J Surg Res ; 245: 212-216, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31421365

RESUMEN

BACKGROUND: Pulmonary embolism and deep vein thrombosis are common clinical entities, and the related malpractice suits affect all medical subspecialties. Claims from malpractice litigation were analyzed to understand the demographics of these lawsuits and the common reasons for pursuing litigation. METHODS: Cases entered into the Westlaw database from March 5, 1987, to May 31, 2018, were reviewed. Search terms included "pulmonary embolism" and "deep vein thrombosis." RESULTS: A total of 277 cases were identified. The most frequently identified defendant was an internist (including family practitioner; 33%), followed by an emergency physician (18%), an orthopedic surgeon (16%), and an obstetrician/gynecologist (9%). The most common etiology for pulmonary embolism was prior surgery (41%). The most common allegation was "failure to diagnose and treat" in 62%. Other negligence included the failure to administer prophylactic anticoagulation while in the hospital (18%), failure to prescribe anticoagulation on discharge (8%), failure to administer anticoagulation after diagnosis (8%), and premature discontinuation of anticoagulation (2%). The most frequently claimed injury was death in 222 cases (80%). Verdicts were found for the defendant in 57% of cases and for the plaintiff in 27% and settled in 16%. CONCLUSIONS: The most frequently cited negligent act was the failure to give prophylactic anticoagulation, even after discharge. The trends noted in this study may potentially be addressed and therefore prevented by systems-based practice changes. The most common allegation, "failure to diagnose and treat," suggests that first-contact doctors such as emergency physicians and primary care practitioners must maintain a high index of suspicion for deep vein thrombosis/pulmonary embolism.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Mala Praxis/estadística & datos numéricos , Médicos/estadística & datos numéricos , Embolia Pulmonar/terapia , Trombosis de la Vena/terapia , Anticoagulantes/uso terapéutico , Bases de Datos Factuales/estadística & datos numéricos , Diagnóstico Tardío/economía , Diagnóstico Tardío/legislación & jurisprudencia , Diagnóstico Tardío/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/economía , Fracaso de Rescate en Atención a la Salud/legislación & jurisprudencia , Humanos , Consentimiento Informado/legislación & jurisprudencia , Consentimiento Informado/estadística & datos numéricos , Mala Praxis/economía , Médicos/economía , Médicos/legislación & jurisprudencia , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiología , Embolia Pulmonar/mortalidad , Estados Unidos/epidemiología , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/etiología , Trombosis de la Vena/mortalidad
3.
J Surg Oncol ; 120(8): 1327-1334, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31680251

RESUMEN

BACKGROUND: Despite the popularity of the U.S. News and World Report (USNWR) hospital rankings among the general public, the relationship between hospital rankings and actual patient outcomes for major cancers remains poorly investigated. METHODS: Medicare Inpatient Standard Analytic Files were queried from 2013-2015 to assess the relationship of postoperative outcomes and Medicare expenditures among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer at hospitals ranked in the top-50 USNWR vs hospitals ranked below 50. RESULTS: Among 94 599 patients, 13 217 vs 81 382 patients underwent surgery at a top-50 hospital versus a non-top 50 ranked hospital. Other than among patients who underwent colorectal surgery, the odds of postoperative complications were lower at top ranked vs non-top ranked hospitals (colorectal: OR, 1.46, 95% CI, 1.28-1.65; lung: OR, 0.73, 95% CI, 0.61-0.87; esophagus: OR, 0.70, 95% CI, 0.52-0.94; pancreas: OR, 0.81, 95% CI, 0.70-0.94; liver: OR, 0.85, 95% CI, 0.69-1.04). Moreover, the odds of 90-day mortality were lower at top ranked hospitals vs non-top ranked hospitals (colorectal: OR, 0.59, 95% CI, 0.48-74; lung: OR, 0.66, 95% CI, 0.53-0.82; esophagus: OR, 0.56, 95% CI, 0.40-0.80; pancreas: OR, 0.51, 95% CI, 0.40-0.65; liver: OR, 0.61, 95% CI, 0.44-0.84). Outcomes were comparable among hospitals within the top-50 rank. CONCLUSION: Mortality rates were lower at hospitals in the top-50 USNWR versus non-top ranked, yet hospitals within the top-50 USNWR rankings had comparable outcomes.


Asunto(s)
Hospitales/estadística & datos numéricos , Neoplasias/mortalidad , Neoplasias/cirugía , Anciano , Anciano de 80 o más Años , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Readmisión del Paciente/estadística & datos numéricos , Publicaciones Periódicas como Asunto , Complicaciones Posoperatorias/epidemiología , Estados Unidos/epidemiología
4.
Surgery ; 166(5): 778-784, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31307773

RESUMEN

BACKGROUND: Hospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals. METHODS: The National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals. RESULTS: Of an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals. CONCLUSION: Safety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Electivos/efectos adversos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Proveedores de Redes de Seguridad/estadística & datos numéricos , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto Joven
5.
Surgery ; 165(6): 1116-1121, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-31072669

RESUMEN

BACKGROUND: Failure to rescue is defined as death after a complication and has been used to evaluate quality of care in adult trauma patients, but there are no published studies on failure to rescue in pediatric trauma. The aim of this study was to define the relationship among rates of mortality, complications, and failure to rescue at centers caring for pediatric (<18 years of age) trauma patients in a nationally representative database. METHODS: We performed a retrospective cohort study of the 2015 and 2016 National Trauma Data Bank. We included patients <18 years of age with an Injury Severity Score of ≥9. We excluded centers with <50 pediatric patients or that reported no complications. We calculated the complication, failure to rescue, mortality, and precedence rates by center and divided centers into tertiles of mortality. We compared complication and failure-to-rescue rates between high and low tertiles of mortality using the Kruskal-Wallis test. RESULTS: Of 62,190 patients from 284 centers, 2,204 patients had at least 1 complication for an overall complication rate of 4% (center level 0%-15%), and 120 patients died after a complication for an overall failure-to-rescue rate of 5% (center level 0%-67%). High-mortality centers had both higher failure-to-rescue rates (10% vs 0.6%, P < .001) and higher complication rates (5% vs 4%, P = .001) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (interquartile range 0%-25%). CONCLUSION: Both complication and failure-to-rescue rates are low in the pediatric injury population, but both complication and failure-to-rescue rates are higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of failure to rescue as a valid center-level metric in this population, but further investigation into individual failure-to-rescue cases may reveal important opportunities for improvement.


Asunto(s)
Benchmarking/métodos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Centros Traumatológicos/estadística & datos numéricos , Heridas y Traumatismos/mortalidad , Adolescente , Benchmarking/estadística & datos numéricos , Niño , Preescolar , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Mejoramiento de la Calidad , Estudios Retrospectivos , Heridas y Traumatismos/complicaciones , Heridas y Traumatismos/diagnóstico
6.
J Surg Res ; 235: 529-535, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30691839

RESUMEN

BACKGROUND: Failure to rescue (FTR) refers to death after a major complication. Defining the optimal context in which to reduce FTR after injury requires knowledge of where and when FTR events occur. MATERIALS AND METHODS: Retrospective observational study of patients >16 y with a minimum Abbreviated Injury Score ≥2 at all 30 level I and II Pennsylvania trauma centers (2007-2015). Location and timing of the first major complication were collected. Complication, mortality, and FTR rates were calculated by location (prehospital, emergency department, operating room, stepdown unit, interventional radiology, intensive care unit (ICU), radiology, and the surgical ward) and by postadmission day. Kruskal-Wallis and chi-squared tests were used to compare variables. RESULTS: Major complications occurred in 15,388 of 178,602 (8.6%) patients. The median age was 58 y (interquartile range [IQR] 37-77 y), 78% were Caucasian, 68% were male, 89% were bluntly injured, and the median Injury Severity Score was 19 (IQR 10-29). Death occurred in 2512 of 15,388 patients with a major complication, for an FTR rate of 16.3%. Compared with non-FTR, FTR had earlier major complications (median day 2 [IQR 0-5 d] versus day 4 [IQR 2-8 d], P < 0.001). FTR rates were highest in the prehospital setting (42%), the operating room (33%), and the emergency department (32%), but the greatest number (1608 of 2512 total FTR events, 64%) occurred in the ICU. Pulmonary (32%) and cardiac (26%) complications most frequently contributed to FTR deaths. CONCLUSIONS: Interventions designed to reduce FTR after injury should focus on pulmonary and cardiac complications in the ICU.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Cardiopatías/mortalidad , Enfermedades Pulmonares/mortalidad , Complicaciones Posoperatorias/mortalidad , Adulto , Anciano , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Pennsylvania/epidemiología , Estudios Retrospectivos
7.
World J Gastroenterol ; 25(2): 258-268, 2019 Jan 14.
Artículo en Inglés | MEDLINE | ID: mdl-30670914

RESUMEN

BACKGROUND: Anastomotic leakage (AL) is a severe complication associated with high morbidity and mortality after radical gastrectomy (RG) for gastric cancer (GC). We hypothesized that a novel abdominal negative pressure lavage-drainage system (ANPLDS) can effectively reduce the failure-to-rescue (FTR) and the risk of reoperation, and it is a feasible management for AL. AIM: To report our institution's experience with a novel ANPLDS for AL after RG for GC. METHODS: The study enrolled 4173 patients who underwent R0 resection for GC at our institution between June 2009 and December 2016. ANPLDS was routinely used for patients with AL after January 2014. Characterization of patients who underwent R0 resection was compared between different study periods. AL rates and postoperative outcome among patients with AL were compared before and after the ANPLDS therapy. We used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with AL and FTR after AL. RESULTS: AL occurred in 83 (83/4173, 2%) patients, leading to 7 deaths. The mean time of occurrence of AL was 5.6 days. The AL rate was similar before (2009-2013, period 1) and after (2014-2016, period 2) the implementation of the ANPLDS therapy (1.7% vs 2.3%, P = 0.121). Age and malnourishment were independently associated with AL. The FTR rate and abdominal bleeding rate after AL occurred were respectively 8.4% and 9.6% for the entire period; however, compared with period 1, this significantly decreased during period 2 (16.2% vs 2.2%, P = 0.041; 18.9% vs 2.2%, P = 0.020, respectively). Moreover, the reoperation rate was also reduced in period 2, although this result was not statistically significant (13.5% vs 2.2%, P = 0.084). Additionally, only ANPLDS therapy was an independent protective factor for FTR after AL (P = 0.04). CONCLUSION: Our experience demonstrates that ANPLDS is a feasible management for AL after RG for GC.


Asunto(s)
Fuga Anastomótica/terapia , Drenaje/métodos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Gastrectomía/efectos adversos , Neoplasias Gástricas/cirugía , Irrigación Terapéutica/métodos , Factores de Edad , Anciano , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Fuga Anastomótica/mortalidad , Estudios de Factibilidad , Femenino , Gastrectomía/métodos , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Masculino , Desnutrición/complicaciones , Desnutrición/epidemiología , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Estudios Retrospectivos
8.
Ann Surg ; 270(1): 91-94, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-29557884

RESUMEN

OBJECTIVE: To identify hospital staffing models associated with failure to rescue (FTR) rates at low- and high-performing hospitals. BACKGROUND: FTR is an important quality measure in surgical safety and is a metric that hospitals are seeking to improve. Specific unit-level determinants of FTR, however, remain unknown. METHODS: Retrospective, observational study using data from the Michigan Quality Surgical Collaborative, which is a prospectively collected and clinically audited database in the state of Michigan. We identified 44,567 patients undergoing major general or vascular surgery from 2008 to 2012. Our main outcome measures were mortality, complications, and FTR rates. RESULTS: Hospital rates of FTR across low, middle, and high tertiles were 8.9%, 16.5%, and 19.9%, respectively (P < 0.001). Low FTR hospitals tended to have a closed intensive care unit staffing model (56% vs 20%, P < 0.001) and a higher proportion of board-certified intensivists (88% vs 60%, P < 0.001) when compared to high FTR hospitals. There was also significantly more staffing of low FTR hospitals by hospitalists (85% vs 20%, P < 0.001) and residents (62% vs 40%, P < 0.01). Low FTR hospitals were noted to have more overnight coverage (75% vs 45%, P < 0.001) as well as a dedicated rapid response team (90% vs 60%, P < 0.001). CONCLUSIONS: Low FTR hospitals had significantly more staffing resources than high FTR hospitals. Although hiring additional staff may be beneficial, there remain significant financial limitations for many hospitals to implement robust staffing models. Thus, our ongoing work seeks to improve rescue and implement effective staffing strategies within these constraints.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Fuerza Laboral en Salud/estadística & datos numéricos , Seguridad del Paciente/estadística & datos numéricos , Admisión y Programación de Personal/estadística & datos numéricos , Personal de Hospital/provisión & distribución , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Auditoría Clínica , Estudios Transversales , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Michigan , Persona de Mediana Edad , Admisión y Programación de Personal/organización & administración , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Mejoramiento de la Calidad/estadística & datos numéricos , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos
9.
J Nurs Care Qual ; 34(2): 107-113, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30095509

RESUMEN

BACKGROUND: Episodic vital sign collection (eVSC), as single data points, gives an incomplete picture of adult patients' postoperative physiologic status. LOCAL PROBLEM: Late detection of patient deterioration resulted in poor patient outcomes on a postsurgical unit. METHODS: Baseline demographic and outcome data were collected through retrospective chart review of all patients admitted to the surgical unit for 12 weeks prior to this quality improvement project. Data on the same outcomes were collected during the 12-week project. INTERVENTION: This project compared outcomes between the current standard of eVSC and the proposed standard of continuous vital sign monitoring (cVSM). RESULTS: Using cVSM demonstrated a statistically significant 27% decrease in the complication rate, and a clinically significant decrease in transfers to an intensive care unit and failure-to-rescue (FTR) events rate. CONCLUSIONS: cVSM demonstrated detection of early signs of patient deterioration to prevent FTR.


Asunto(s)
Deterioro Clínico , Pacientes Internos , Monitoreo Fisiológico/métodos , Signos Vitales/fisiología , Adulto , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Humanos , Estudios Longitudinales , Personal de Enfermería en Hospital/estadística & datos numéricos , Complicaciones Posoperatorias , Mejoramiento de la Calidad , Estudios Retrospectivos
10.
J Surg Res ; 233: 397-402, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30502276

RESUMEN

BACKGROUND: Failure to rescue (FTR) is considered as an index of quality of care provided by a hospital. However, the role of frailty in FTR remains unclear. We hypothesized that the FTR rate is higher for frail geriatric emergency general surgery (EGS) patients than nonfrail geriatric EGS patients. METHODS: We performed a 3-y (2015-2017) prospective cohort study of all geriatric patients (age ≥ 65 y) requiring EGS. Frailty was calculated by using the EGS-specific Frailty Index (EGSFI) within 24 h of admission. Patients were divided into two groups: frail (FI ≥ 0.325) and nonfrail (FI < 0.325). We defined FTR as death from a major complication. Regression analysis was performed to control for demographics, type of operative intervention, admission vitals, and admission laboratory values. RESULTS: Three hundred twenty-six geriatric EGS patients were included, of which 38.9% were frail. Frail patients were more likely to be white (P < 0.01) and, on admission, had a higher American Association of Anesthesiologist class (P = 0.03) and lower serum albumin (P < 0.01). However, there was no difference between the groups regarding age (P = 0.54), gender (P = 0.56), admission vitals, and WBC count (P = 0.35). Overall, 26.7% (n = 85) of patients developed in-hospital complications; and mortality occurred in 30% (n = 26) of those patients (i.e., the FTR group). Frail patients had higher rates of FTR (14% vs. 4%, P < 0.001) than nonfrail patients. On regression analysis, after controlling for confounders, frail status was an independent predictor of FTR (OR: 3.4 [2.3-4.6]) in geriatric EGS patients. CONCLUSIONS: Our study demonstrates that in geriatric EGS patients, a frail status independently contributes to FTR and increases the odds of FTR threefold compared with nonfrail status. Thus, it should be included in quality metrics for geriatric EGS patients.


Asunto(s)
Tratamiento de Urgencia/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Fragilidad/diagnóstico , Evaluación Geriátrica , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/efectos adversos , Femenino , Anciano Frágil/estadística & datos numéricos , Fragilidad/complicaciones , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Medición de Riesgo/métodos , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos
11.
J Surg Res ; 234: 1-6, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30527459

RESUMEN

BACKGROUND: Failure to rescue (FTR) is an important measure of quality of care. The aim of this study was to assess FTR in patients with colon cancer (CC) who underwent surgical resection. We hypothesized that patient managed in urban centers had lower FTR. METHODS: We performed a 1-y (2011) retrospective analysis of the National Inpatient Sample database and identified all patients with CC who underwent surgical management. Patients were stratified based on the location of treatment: urban versus rural. Outcome measure was FTR, which was defined as death after major complications. Regression analysis was performed to evaluate the independent predictors of FTR. RESULTS: A total of 49,789 patients with CC who underwent surgery were analyzed. The mean age was 71 ± 20.2 y and 59% were males. About 21.5% patients developed in-hospital complications. The overall rates of complications, mortality, and FTR were 21.5%, 3.0%, and 33.8% respectively. Patient managed in rural centers had higher FTR compared with urban centers (39.5% versus 30.1%, P = 0.01). On regression analysis after controlling for age, gender, type of procedure, Charlson Comorbidity Index, and insurance status, management in rural center was independently associated with FTR (odds ratio: 1.9 [1.4-3.7]). On subanalysis of urban centers, management in teaching urban hospital was independently associated with higher FTR (odds ratio: 1.4 [1.2-3.8]). CONCLUSIONS: Disparities exist among centers managing patients with CC undergoing surgical intervention. Rural centers have higher FTR compared with similar cohort of patients managed in urban centers. Teaching urban hospital performed worse than nonteaching urban centers. Understanding the reason for these differences may help standardize care across centers and help improve patient outcomes.


Asunto(s)
Neoplasias del Colon/cirugía , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Hospitales Rurales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Retrospectivos , Estados Unidos/epidemiología
12.
Langenbecks Arch Surg ; 404(1): 93-101, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30552508

RESUMEN

PURPOSE: This observational study explored the association between hospital volume and short-term outcome following gastric resections for non-bariatric indication, aiming to contribute to the discussion on centralization of complex visceral surgery in Germany. METHODS: Based on complete national hospital discharge data from 2010 to 2015, the association between hospital volume and in-hospital mortality was evaluated according to volume quintiles and volume deciles. Case-mix differences regarding surgical indication, age, sex, and comorbidities were considered for risk adjustment. In addition, rates of major complications and failure to rescue were analyzed across hospital volume categories. RESULTS: Inpatient episodes (72,528) with gastric resection were analyzed. Risk-adjusted mortality in patients treated in very low volume hospitals (median volume of 5 surgeries per year) was higher (12.0% [95% CI 11.4 to 12.5]) compared to those treated in very high volume hospitals (50 surgeries per year; 10.6% [10.0 to 11.1]). Failure to rescue patients with complications was 28.1% [27.0 to 29.3] in very low volume hospitals and 22.7% [21.6 to 23.8] in very high volume hospitals. Differences were similar within the subgroup of patients operated for gastric cancer. CONCLUSIONS: Treatment in very high volume hospitals is associated with a lower in-hospital mortality compared to treatment in very low volume hospitals. This effect seems to be determined by the ability to rescue patients who experience complications. As the observed benefit is only related to very high volumes, the results do not clearly indicate that centralization may improve short-term results substantially, unless a very high degree of centralization would be achieved. Possibly, further research focusing on other outcome measures, such as clinical processes or long-term results, might lead to divergent conclusions.


Asunto(s)
Gastrectomía/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Hospitales de Alto Volumen/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Gastropatías/cirugía , Anciano , Grupos Diagnósticos Relacionados , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Gastrectomía/efectos adversos , Gastrectomía/mortalidad , Alemania , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Gastropatías/mortalidad , Gastropatías/patología
13.
J Surg Res ; 231: 62-68, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30278970

RESUMEN

BACKGROUND: Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events. METHODS: A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR). RESULTS: There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients. CONCLUSIONS: Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS.


Asunto(s)
Servicios Médicos de Urgencia/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Cirugía General/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Grupos de Población Continentales , Femenino , Mortalidad Hospitalaria , Humanos , Cobertura del Seguro , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología
14.
J Gastrointest Surg ; 22(10): 1688-1696, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29855870

RESUMEN

OBJECTIVE: To estimate the cost of rescue and cost of failure and determine cost-effectiveness of rescue from major complications at high-volume (HV) and low-volume (LV) centers METHODS: Ninety-six thousand one hundred seven patients undergoing liver resection were identified from the Nationwide Inpatient Sample (NIS) between 2002 and 2011. The incremental cost of rescue and cost of FTR were calculated. Using propensity-matched cohorts, a cost-effectiveness analysis was performed to determine the incremental cost-effectiveness ratio (ICER) between HV and LV hospitals. RESULTS: Ninety-six thousand one hundred seven patients were identified in NIS. The overall mortality was 2.3% and was lowest in HV centers (HV 1.4% vs. MV 2.1% vs. LV 2.6%; p < 0.001). Major complications occurred in 14.9% of hepatectomies and were comparable regardless of volume (HV 14.2% vs. MV 14.3% vs. LV 15.4%; p < 0.001). The FTR rate was substantially lower among HV centers (HV 7.7%, MV 11%, LV 12%; p < 0.001). At a willingness to pay benchmark of $50,000 per year of life saved, both HV (ICER = $3296) and MV (ICER = $4182) centers were cost-effective at rescuing patients from a major complication compared to LV hospitals. CONCLUSION: Not only was FTR less common at HV hospitals, but the management of most major complications was cost-effective at higher volume centers.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/economía , Hepatectomía/economía , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Anciano , Análisis Costo-Beneficio , Bases de Datos Factuales , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Hepatectomía/mortalidad , Mortalidad Hospitalaria , Hospitales de Bajo Volumen/economía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estados Unidos/epidemiología
15.
JAMA Surg ; 153(5): e180214, 2018 05 16.
Artículo en Inglés | MEDLINE | ID: mdl-29562073

RESUMEN

Importance: Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. Objective: To assess the association of frailty with FTR in patients undergoing inpatient surgery. Design, Setting, and Participants: This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. Main Outcomes and Measures: The number of postoperative complications and inpatient FTR. Results: A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5% for those with scores of 10 or less, 23.7% for those with scores of 11 to 20, 31.1% for those with scores of 21 to 30, 42.5% for those with scores of 31 to 40, and 54.4% for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95% CI, 3.9-7.1). Odds ratios were 8.1 (95% CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95% CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95% CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95% CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95% CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95% CI, 8.1-9.9; vs RAI score >40: 18.4; 95% CI, 15.7-21.4). Conclusions and Relevance: Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Fragilidad/mortalidad , Complicaciones Posoperatorias/mortalidad , Mejoramiento de la Calidad , Medición de Riesgo/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/mortalidad , Adulto , Anciano , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Estados Unidos/epidemiología
16.
World J Surg ; 42(10): 3372-3380, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29572565

RESUMEN

BACKGROUND AND OBJECTIVES: It is increasingly accepted that quality of colon cancer surgery might be secured by combining volume standards with audit implementation. However, debate remains about other structural factors also influencing this quality, such as hospital teaching status. This study evaluates short-term outcomes after colon cancer surgery of patients treated in general, teaching or academic hospitals. METHODS: All patients (n = 23,593) registered in the Dutch Colorectal Audit undergoing colon cancer surgery between 2011 and 2014 were included. Patients were divided into groups based on teaching status of their hospital. Main outcome measures were serious complications, failure to rescue (FTR) and 30-day or in-hospital mortality. Multivariate logistic regression models on these outcome measures and with hospital teaching status as primary determinant were used, adjusted for case-mix, year of surgery and hospital volume. RESULTS: Patients treated in teaching and academic hospitals showed higher adjusted serious complication rates, compared to patients treated in general hospitals (odds ratio 1.25 95% CI [1.11-1.39] and OR 1.23 [1.05-1.46]). However, patients treated in teaching hospitals had lower adjusted FTR rates than patients treated in general hospitals (OR 0.63 [0.44-0.89]). However, for all outcomes there was considerable between-hospitals variation within each type of teaching status. CONCLUSION: On average, patients treated in general hospitals had lower serious complication rates, but patients treated in teaching hospitals had more favorable FTR rates. Given the hospital variation within each hospital teaching type, it is possible to deliver excellent care regardless of the hospital teaching type.


Asunto(s)
Neoplasias del Colon/cirugía , Hospitales Generales , Hospitales de Enseñanza , Adulto , Anciano , Anciano de 80 o más Años , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Auditoría Médica , Persona de Mediana Edad , Países Bajos , Oportunidad Relativa , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología
17.
JSLS ; 22(1)2018.
Artículo en Inglés | MEDLINE | ID: mdl-29472758

RESUMEN

Background and Objectives: Morbidity and mortality have been shown to increase several-fold in patients who have undergone bariatric surgery and returned to the operating room after their initial procedures. Failure-to-rescue (FTR) analyses allow for an understanding of patient management and outcomes that is more distinguished than assessments of adverse occurrences and mortality rates alone. The objective of this study was to assess failure to rescue (FTR) and the characteristics and outcomes of patients undergoing reoperation after laparoscopic gastric bypass (LGBP) and laparoscopic sleeve gastrectomy (LSG). Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) participant data files were accessed to identify patients >18 years of age who underwent LGBP and LSG from 2011 through 2015. Patients were further classified into 3-day reoperation and nonreoperation cohorts. Patient demographics, comorbidities, and baseline health characteristics were collected. Pertinent outcomes, complications, and FTR were analyzed. Results: A total of 96,538 patients were included. Of those, 1,850 (1.92%) returned to the operating room, and 94,688 (98.08%) did not. Patients who underwent reoperation had a greater likelihood of having any complication (72.20% vs. 51.29%; P < .0001) and had a higher overall mortality rate (1.46% vs. 0.10%, P < .0001). The FTR rates were 2.01% in the reoperation group and 0.14% in the nonreoperation group (P < .0001). Conclusion: Patients who undergo LGBP and LSG and have reoperations are at higher risk of developing complications with subsequent mortality.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Gastrectomía , Derivación Gástrica , Laparoscopía , Obesidad Mórbida/cirugía , Reoperación/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Gastrectomía/métodos , Derivación Gástrica/métodos , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo
18.
Urol Oncol ; 36(4): 156.e1-156.e7, 2018 04.
Artículo en Inglés | MEDLINE | ID: mdl-29153941

RESUMEN

PURPOSE: Patients readmitted to secondary hospitals rather than the primary hospital where their surgery took place may be at risk for poorer outcomes. We sought to evaluate the effect of site of readmission on failure-to-rescue complication rates following urologic cancer surgery. MATERIALS AND METHODS: Retrospective review of major urologic cancer surgeries in the Washington State Comprehensive Hospital Abstract Reporting System between 1998 and 2013. Failure-to-rescue (FTR) rates, defined as inpatient death after a complication requiring hospital readmission, were compared between patients readmitted to their primary hospital with those readmitted to a secondary hospital. Multivariable logistic regression (MVA) models evaluated the association between readmission site and FTR. RESULTS: Of 31,498 eligible patients, 3,113 patients were readmitted to hospital within 90 days of surgery, of whom 29.2% were readmitted to a secondary hospital. The highest FTR rates were following cardiac (11.6%), respiratory (11.2%), and sepsis-related complications (10.0%). When limiting to patients who underwent surgery in a high-volume center, the odds of FTR were 4-fold higher when complications were managed in a secondary hospital (OR = 4.06, 95% CI: 1.67-9.89). CONCLUSIONS: The institution where patients present for postoperative complications is associated with differential mortality outcomes. Upon validation in a large cohort, these findings may inform quality improvement initiatives that target postoperative readmissions, algorithm-based approaches to post-surgical management of complications, and guide clinical decision-making around hospital transfers.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Neoplasias Urológicas/cirugía , Procedimientos Quirúrgicos Urológicos/efectos adversos , Anciano , Toma de Decisiones Clínicas , Femenino , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Transferencia de Pacientes/normas , Complicaciones Posoperatorias/etiología , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Medición de Riesgo , Resultado del Tratamiento , Neoplasias Urológicas/epidemiología , Washingtón/epidemiología
19.
Neurosurgery ; 83(2): 263-269, 2018 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-28973498

RESUMEN

BACKGROUND: There is growing recognition that perioperative complication rates are similar between hospitals, but mortality rates are lower at high-volume centers. This may be due to differences in the ability to rescue patients from major complications. OBJECTIVE: To examine the relationship between hospital caseload and failure to rescue from complications following resection of intracranial neoplasms. METHODS: We identified adults in the Nationwide Inpatient Sample diagnosed with glioma, meningioma, brain metastasis, or acoustic neuroma, who underwent surgical resection between 1998 and 2010. We stratified hospitals by low, intermediate, and high surgical volume tertiles and calculated failure to rescue rates (mortality in patients after a major complication). RESULTS: A total of 550 054 patients were analyzed. Overall risk-adjusted complication rates were comparable between low- and medium-volume centers, and slightly lower at high-volume centers (15.3% [15.2, 15.5] vs 15.7% [15.5, 15.9] vs 14.3% [14.1, 14.6]). Risk-adjusted mortality decreased with increasing hospital surgical volume (10.3% [10.2, 10.5] vs 9.0% [8.9, 9.1] vs 7.1% [7.0, 7.2]). The overall risk-adjusted failure to rescue rate also decreased with increasing surgical volume (26.9% [26.3, 27.4] vs 24.8% [24.3, 25.3] vs 20.9% [20.5, 21.5]). CONCLUSION: While complication rates were similar between high-volume and low-volume hospitals following craniotomy for tumor, mortality rates were substantially lower at high-volume centers. This appears to be due to the ability of high-volume hospitals to rescue patients from major perioperative complications.


Asunto(s)
Neoplasias Encefálicas/mortalidad , Neoplasias Encefálicas/cirugía , Craneotomía/mortalidad , Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Complicaciones Posoperatorias/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Craneotomía/efectos adversos , Femenino , Mortalidad Hospitalaria , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología
20.
Hosp Pediatr ; 7(12): 710-715, 2017 12.
Artículo en Inglés | MEDLINE | ID: mdl-29133291

RESUMEN

BACKGROUND AND OBJECTIVES: Improved situation awareness may prevent unplanned ICU transfers. Transfers with serious safety issues may be classified as unrecognized situation awareness failure events (UNSAFE) and are associated with intubation, vasopressors, or >3 fluid boluses within 1 hour before or after ICU arrival. Our aim was to decrease the proportion of unplanned ICU transfers that met UNSAFE criteria by 50% in 1 year. METHODS: We adapted a previously described huddle-based intervention. In May 2015, we started a daily safety brief with hospital-wide representation; concurrently, nurses and residents separately identified watcher patients (ie, patients at risk for UNSAFE transfers) to be reported in the daily safety brief. Watcher patients frequently differed between the groups, so in July 2015, we started twice-daily watcher huddles on a pilot floor. During these huddles, nurses and residents jointly identified watcher patients on the basis of defined criteria and deployed mitigation plans. By March 2016, we implemented these huddles hospital-wide. We reviewed the electronic medical record to categorize all unplanned ICU transfers as safe or UNSAFE. Our outcome was the proportion of unplanned ICU transfers that met UNSAFE criteria. RESULTS: In the 16-month pre-intervention period, 49 of the 322 unplanned ICU transfers were UNSAFE (median 15.5%); in the 12-month post-intervention period, 13 of the 329 unplanned ICU transfers were UNSAFE (median 3%). These findings represent an 81% reduction in the proportion of UNSAFE transfers. CONCLUSIONS: Watcher huddles incorporated into the daily inpatient routine can significantly decrease UNSAFE transfers.


Asunto(s)
Fracaso de Rescate en Atención a la Salud/estadística & datos numéricos , Fracaso de Rescate en Atención a la Salud/normas , Unidades de Cuidados Intensivos/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Niño , Humanos , Estudios Retrospectivos , Factores de Tiempo
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