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2.
J Trauma Acute Care Surg ; 93(2): 176-186, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35444147

RESUMO

BACKGROUND: Failure to rescue (FTR) is defined as mortality following a complication. Failure to rescue has come under scrutiny as a quality metric to compare trauma centers. In contrast to elective surgery, trauma has an early period of high expected mortality because of injury sequelae rather than a complication. Here, we report FTR in early and late mortality using an externally validated trauma patient database, hypothesizing that centers with higher risk-adjusted mortality rates have higher risk-adjusted FTR rates. METHODS: The study included 114,220 patients at 34 Levels I and II trauma centers in a statewide quality collaborative (2016-2020) with Injury Severity Score of ≥5. Emergency department deaths were excluded. Multivariate regression models were used to produce center-level adjusted rates for mortality and major complications. Centers were ranked on adjusted mortality rate and divided into quintiles. Early deaths (within 48 hours of presentation) and late deaths (after 48 hours) were analyzed. RESULTS: Overall, 6.7% of patients had a major complication and 3.1% died. There was no difference in the mean risk-adjusted complication rate among the centers. Failure to rescue was significantly different across the quintiles (13.8% at the very low-mortality centers vs. 23.4% at the very-high-mortality centers, p < 0.001). For early deaths, there was no difference in FTR rates among the highest and lowest mortality quintiles. For late deaths, there was a twofold increase in the FTR rate between the lowest and highest mortality centers (9.7% vs. 19.3%, p < 0.001), despite no difference in the rates of major complications (5.9% vs. 6.0%, p = 0.42). CONCLUSION: Low-performing trauma centers have higher mortality rates and lower rates of rescue following major complications. These differences are most evident in patients who survive the first 48 hours after injury. A better understanding of the complications and their role in mortality after 48 hours is an area of interest for quality improvement efforts. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.


Assuntos
Falha da Terapia de Resgate , Centros de Traumatologia , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Complicações Pós-Operatórias , Melhoria de Qualidade , Estudos Retrospectivos
3.
Can J Surg ; 65(2): E215-E220, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35318241

RESUMO

BACKGROUND: The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. METHODS: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). RESULTS: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. CONCLUSION: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.


Assuntos
Falha da Terapia de Resgate , Cirurgia Geral , Alberta , Mortalidade Hospitalar , Humanos , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade , Estudos Retrospectivos
4.
HPB (Oxford) ; 24(6): 885-892, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34801400

RESUMO

BACKGROUND: Obesity has traditionally been considered a cause of increased surgical complexity and poor outcomes following pancreatoduodenectomy (PD). This study aimed at evaluating the role of obesity in terms of mortality and failure to rescue (FTR), with a particular focus on nonmalignant tumors. METHODS: All patients undergoing elective PD over 10 consecutive years were analyzed. Patients were stratified according to their BMI and categorized into two groups. Predictors of mortality and FTR were assessed through logistic regression. RESULTS: Out of 1865 patients included, 151 were obese (8.1%). Overall mortality and FTR were 3.1% and 14.1%, respectively. In obese patients, mortality was 6.0% and FTR 26.5%, significantly higher compared to nonobese (p < 0.05). In the multivariable analysis, obesity, age > 70 years, and ASA-PS score were independent predictors of mortality and FTR. Postoperative pancreatic fistula (35.8% vs. 25.8%), postpancreatectomy acute pancreatitis (24.5% vs. 12.5%), and chyle leak (6.0% vs. 3.2%) were more frequent among obese patients. In the subgroup of patients with nonmalignant tumors (n = 443), obesity was the only independent predictor of FTR. CONCLUSION: PD performed in obese patients was associated with higher surgical morbidity and mortality. When dealing with nonmalignant tumors, deferring surgery in obese patients should be strongly considered.


Assuntos
Falha da Terapia de Resgate , Neoplasias , Pancreatite , Doença Aguda , Idoso , Humanos , Neoplasias/complicações , Obesidade/complicações , Pancreaticoduodenectomia/efeitos adversos , Pancreatite/complicações , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
5.
J Thorac Cardiovasc Surg ; 163(1): 151-160.e6, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32563575

RESUMO

OBJECTIVE: Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery. METHODS: We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. RESULTS: In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. CONCLUSIONS: In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Idoso Fragilizado/estatística & dados numéricos , Fragilidade , Cardiopatias , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Cardiopatias/epidemiologia , Cardiopatias/cirurgia , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Prognóstico , Fatores de Risco , Estados Unidos/epidemiologia
6.
Am Surg ; 87(11): 1760-1765, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34727744

RESUMO

INTRODUCTION: The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. METHODS: The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS: 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality (P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality (P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). CONCLUSIONS: Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.


Assuntos
Falha da Terapia de Resgate/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Bases de Dados como Assunto , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/patologia , Ferimentos e Lesões/terapia
7.
JAMA Netw Open ; 4(8): e2118449, 2021 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-34342653

RESUMO

Importance: The scientific validity of the Merit-Based Incentive Payment System (MIPS) quality score as a measure of hospital-level patient outcomes is unknown. Objective: To examine whether better physician performance on the MIPS quality score is associated with better hospital outcomes. Design, Setting, and Participants: This cross-sectional study of 38 830 physicians used data from the Centers for Medicare & Medicaid Services (CMS) Physician Compare (2017) merged with CMS Hospital Compare data. Data analysis was conducted from September to November 2020. Main Outcomes and Measures: Linear regression was used to examine the association between physician MIPS quality scores aggregated at the hospital level and hospitalwide measures of (1) postoperative complications, (2) failure to rescue, (3) individual postoperative complications, and (4) readmissions. Results: The study cohort of 38 830 clinicians (5198 [14.6%] women; 12 103 [31.6%] with 11-20 years in practice) included 6580 (17.2%) general surgeons, 8978 (23.4%) orthopedic surgeons, 1617 (4.2%) vascular surgeons, 582 (1.5%) cardiac surgeons, 904 (2.4%) thoracic surgeons, 18 149 (47.4%) anesthesiologists, and 1520 (4.0%) intensivists at 3055 hospitals. The MIPS quality score was not associated with the hospital composite rate of postoperative complications. MIPS quality scores for vascular surgeons in the 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.55-percentage point higher hospital rate of failure to rescue (95% CI, 0.06-1.04 percentage points; P = .03). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.41-percentage point higher hospital coronary artery bypass graft (CABG) mortality rate (95% CI, 0.10-0.71 percentage points; P = .01). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile and 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with 0.65-percentage point (95% CI, 0.013-1.16 percentage points; P = .02) and 0.48-percentage point (95% CI, 0.07-0.90 percentage points; P = .02) higher hospital CABG readmission rates, respectively. Conclusions and Relevance: In this study, better performance on the physician MIPS quality score was associated with better hospital surgical outcomes for some physician specialties during the first year of MIPS.


Assuntos
Competência Clínica/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Médicos/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Reembolso de Incentivo/estatística & dados numéricos , Adulto , Centers for Medicare and Medicaid Services, U.S. , Competência Clínica/normas , Estudos Transversais , Análise de Dados , Falha da Terapia de Resgate/normas , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Hospitais/normas , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Readmissão do Paciente/normas , Readmissão do Paciente/estatística & dados numéricos , Médicos/normas , Complicações Pós-Operatórias/epidemiologia , Avaliação de Programas e Projetos de Saúde , Reembolso de Incentivo/normas , Cirurgiões/normas , Cirurgiões/estatística & dados numéricos , Estados Unidos
8.
J Korean Med Sci ; 36(34): e243, 2021 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-34463065

RESUMO

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may increase the total number of suicide attempts and the proportion of low-rescue attempts. We investigated the factors affecting low-rescue suicide attempts using the risk-rescue rating scale (RRRS) among patients who visited the emergency department (ED) after attempting suicide before or during the COVID-19 pandemic. METHODS: We retrospectively investigated suicide attempts made by patients who visited our ED from March 2019 to September 2020. Patients were classified into two groups based on whether they attempted suicide before or during the COVID-19 pandemic. Data on demographic variables, psychiatric factors, suicide risk factors and rescue factors were collected and compared. RESULTS: A total of 518 patients were included in the study, 275 (53.1%) of whom attempted suicide during the COVID-19 pandemic. The proportion of patients who made low-rescue suicide attempts differed before and during the COVID-19 pandemic (37.1% vs. 28.8%) (P = 0.046). However, the proportions of patients who made high-risk suicide attempts and high-lethality suicide attempts did not significantly differ between the two periods. The independent risk factors for low-rescue suicide attempts were age and the COVID-19 pandemic (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03; P = 0.006) (OR, 1.52; 95% CI, 1.03-2.25; P = 0.034). CONCLUSION: The COVID-19 pandemic was associated with low-rescue suicide attempts in patients visiting the ED after attempting suicide. Thus, we need to consider the implementation of measures to prevent low-rescue suicide attempts during similar infectious disease crises.


Assuntos
COVID-19/epidemiologia , Falha da Terapia de Resgate/estatística & dados numéricos , Tentativa de Suicídio/prevenção & controle , Adolescente , Adulto , COVID-19/virologia , Serviço Hospitalar de Emergência , Feminino , Hospitais Universitários , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2/isolamento & purificação , Tentativa de Suicídio/estatística & dados numéricos , Centros de Atenção Terciária , Adulto Jovem
9.
Ann Surg ; 274(5): e452-e459, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34225297

RESUMO

OBJECTIVE: To investigate the association between hospital volume and failure to rescue (FtR), after open repair (OAR), and endovascular repair (EVAR) of intact abdominal aortic aneurysms (AAA) among centers participating in the VASCUNET and International Consortium of Vascular Registries. SUMMARY OF BACKGROUND DATA: FtR (ie, in-hospital death following major complications) is a composite end-point representing the inability to treat complications effectively and prevent death. METHODS: Using data from 8 vascular registries, complication and mortality rates after intact AAA repair were examined (n = 60,273; EVAR-43,668; OAR-16,605). A restricted analysis using pooled data from 4 countries (Australia, Hungary, New Zealand, and USA) reporting data on all postoperative complications (bleeding, stroke, cardiac, respiratory, renal, colonic ischemia) was performed to identify risk-adjusted association between hospital volume and FtR. RESULTS: The most frequently reported complications were cardiac (EVAR-3.0%, OAR-8.9%) and respiratory (EVAR-1.0%, OAR-5.7%). In adjusted analysis, 4.3% of EVARs and 18.5% of OARs had at least 1 complication. The overall FtR rate was 10.3% after EVAR and 15.7% after OAR. Subjects treated in the highest volume centers (Q4) had 46% and 80% lower odds of FtR after EVAR (OR = 0.54; 95% CI = 0.34-0.87; P = 0.04) and OAR (OR = 0.22; 95% CI = 0.11-0.44; P < 0.001) when compared to lowest volume centers (Q1), respectively. Colonic ischemia had the highest risk of FtR for both procedures (adjusted predicted risks, EVAR: 27%, 95% CI 14%-45%; OAR: 30%, 95% CI 17%-46%). CONCLUSIONS: In this multi-national dataset, FtR rate after intact AAA repair with EVAR and OAR is significantly associated with hospital volume. Hospitals in the top volume quartiles achieve the lowest mortality after a complication has occurred.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Falha da Terapia de Resgate/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Idoso , Aneurisma da Aorta Abdominal/mortalidade , Austrália/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Nova Zelândia/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
11.
Ann Surg ; 274(3): 459-466, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34132696

RESUMO

OBJECTIVE: This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA: FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS: Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS: Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS: Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.


Assuntos
Falha da Terapia de Resgate , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/mortalidade , Fatores Etários , Idoso , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , América do Norte/epidemiologia , Radiografia Intervencionista/estatística & dados numéricos , Sistema de Registros , Reoperação/estatística & dados numéricos , Fatores de Risco , Suécia/epidemiologia
12.
HPB (Oxford) ; 23(12): 1837-1848, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34090804

RESUMO

BACKGROUND: Failure to rescue (FTR) is defined as postoperative complications leading to mortality. This nationwide study aimed to assess factors associated with FTR and hospital variation in FTR after liver surgery. METHODS: All patients who underwent liver resection between 2014 and 2017 in the Netherlands were included. FTR was defined as in-hospital or 30-day mortality after complications Dindo grade ≥3a. Variables associated with FTR and nationwide hospital variation were assessed using multivariable logistic regression. RESULTS: Of 4961 patients included, 3707 (74.4%) underwent liver resection for colorectal liver metastases, 379 (7.6%) for other metastases, 526 (10.6%) for hepatocellular carcinoma and 349 (7.0%) for biliary cancer. Thirty-day major morbidity was 11.5%. Overall mortality was 2.3%. FTR was 19.1%. Age 65-80 (aOR: 2.86, CI:1.01-12.0, p = 0.049), ASA 3+ (aOR:2.59, CI: 1.66-4.02, p < 0.001), liver cirrhosis (aOR:4.15, CI:1.81-9.22, p < 0.001), biliary cancer (aOR:3.47, CI: 1.73-6.96, p < 0.001), and major resection (aOR:6.46, CI: 3.91-10.9, p < 0.001) were associated with FTR. Postoperative liver failure (aOR: 26.9, CI: 14.6-51.2, p < 0.001), cardiac (aOR: 2.62, CI: 1.27-5.29, p = 0.008) and thromboembolic complications (aOR: 2.49, CI: 1.16-5.22, p = 0.017) were associated with FTR. After case-mix correction, no hospital variation in FTR was observed. CONCLUSION: FTR is influenced by patient demographics, disease and procedural burden. Prevention of postoperative liver failure, cardiac and thromboembolic complications could decrease FTR.


Assuntos
Falha da Terapia de Resgate , Idoso , Idoso de 80 Anos ou mais , Mortalidade Hospitalar , Hospitais , Humanos , Fígado , Complicações Pós-Operatórias/etiologia , Fatores de Risco
13.
J Surg Res ; 266: 320-327, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34052600

RESUMO

BACKGROUND: Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. MATERIALS AND METHODS: A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5 = 0, mFI-5 = 1, mFI-5 = 2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. RESULTS: A total of 47,216 patients were included: 27.4% with mFI-5 = 0, 45% with mFI-5 = 1, 22.1% with mFI-5 = 2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5 = 1: odds ratio (OR) 1.48, p=0.003; mFI-5 = 2: OR 2.66, p <0.001; mFI-5 ≥ 3: OR 3.97, p <0.001), 30-day complications (mFI-5 = 1: OR 1.46, p <0.001; mFI-5 = 2: OR 2.48, p <0.001; mFI-5≥3: OR 5.01, p <0.001), reoperation (mFI-5 = 1: OR 1.42, p = 0.020; mFI-5 = 2: OR 1.70, p = 0.021; mFI-5 ≥ 3: OR 2.18, p = 0.009) and all-cause mortality (mFI-5 = 1: OR 1.49, p=0.001; mFI-5 = 2: OR 2.67, p <0.001; mFI-5 ≥ 3: 3.96, p <0.001). CONCLUSIONS: Increasing frailty in geriatric EGS patients is associated with significantly higher rates of FTR, 30-day complications, reoperations, and all-cause mortality. The mFI-5 score can be used to assess frailty and better anticipate the postoperative course of vulnerable geriatric patients.


Assuntos
Tratamento de Emergência/mortalidade , Falha da Terapia de Resgate/estatística & dados numéricos , Fragilidade/complicações , Complicações Pós-Operatórias/epidemiologia , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Feminino , Cirurgia Geral , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
14.
J Am Coll Surg ; 233(3): 415-425, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34029677

RESUMO

BACKGROUND: Morbidity after hepatectomy remains a significant, potentially preventable, outcome. Understanding the pattern of complications and rescue pathways is critical for the development of targeted initiatives intended to salvage patients after operative morbidity. STUDY DESIGN: Patients undergoing liver resection from 1991 to 2018 at a single institution were analyzed. Failure to rescue (FTR) was defined as percentage of deaths in patients with a complication within 30 days. Generalized estimating equations with log-link function assessed associations between clinical characteristics and major complications and between complications at fewer than 30 days and 30 to 90 days. Logistic regression assessed associations between complications and FTR. RESULTS: A total of 6,191 patients and 6,668 operations were identified, of which 55.6% were performed for management of metastatic colorectal cancer. Major complications (grade ≥3) occurred in 20.2% of operations (1,346 of 6,668). Ninety-day mortality was 2.2%. The most common complication was intra-abdominal abscess at 9.0% (95% CI, 8.3% to 9.7%). Ten percent of patients with a complication at 30 days had another complication between 30 and 90 days compared with 2% without an early complication (odds ratio [OR] 5.09; 95% CI, 3.97 to 6.54; p < 0.001). FTR for liver failure, cardiac arrest, abscess, and hemorrhage was 36%, 56%, 3%, and 6%, respectively. Risk of 90-day mortality was higher in patients with liver failure (53% vs 2%; OR 61.42; 95% CI, 37.47 to 100.67; p < 0.001), cardiac arrest (69% vs 2%; OR 96.95; 95% CI, 33.23 to 283.80; p < 0.001), hemorrhage (11% vs 2%; OR 5.51; 95% CI, 2.59 to 11.73; p < 0.001), and abscess (7% vs 2%; OR 4.05; 95% CI, 2.76 to 5.94; p < 0.001) compared with those without these complications. CONCLUSIONS: Morbidity after hepatectomy is frequent despite low mortality. This study identifies targets for improvement in morbidity and failure to rescue after hepatectomy. Efforts to improve recognition and intervention for infections and early complications are needed to improve outcomes.


Assuntos
Falha da Terapia de Resgate , Hepatectomia/mortalidade , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/cirurgia , Complicações Pós-Operatórias/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo
16.
Arch. bronconeumol. (Ed. impr.) ; 57(4): 251-255, Abr. 2021. ilus, tab, graf
Artigo em Inglês | IBECS | ID: ibc-208451

RESUMO

Objectives: Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients.Methods: Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care.Results: 2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66–0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720. (AU)


Objetivos: El fallo en el rescate (FTR, por sus siglas en inglés) se define por el número de muertes entre los pacientes que experimentan complicaciones graves tras la cirugía. En este informe analizamos el FTR y realizamos gráficos de control de suma acumulada (CUSUM, por sus siglas en inglés) para monitorizar los resultados en una serie de gran tamaño de pacientes operados de carcinoma de pulmón.Métodos: Se revisaron los datos almacenados prospectivamente de los casos de resección pulmonar anatómica en un centro. Se codificaron los eventos adversos postoperatorios y se incluyeron como una variable binaria (complicaciones graves o menores). También se registró la mortalidad a los 30 días. Los pacientes que murieron después de sufrir complicaciones mayores se consideraron FTR. Se elaboraron gráficos CUSUM ajustados al riesgo, utilizando las variables EuroLung1 y 2, para el análisis de las complicaciones graves y el FTR. Se analizaron los puntos de estancamiento o inversión de la tendencia para detectar los posibles cambios voluntarios o inadvertidos en el plan de cuidados.Resultados: Se incluyeron 2.237 casos. El 9,1% sufrieron complicaciones graves. El número de casos que se consideraron como fallos en el rescate fue de 46 (2,1% del total de la serie y 22,5% de los casos con complicaciones graves). El rendimiento predictivo de los modelos EuroLung1 y 2 fue el siguiente: EuroLung1 (morbilidad grave) índice C: 0,70 (IC 95%: 0,66-0,73); EuroLung2 (aplicado al FTR) índice C: 0,81 (IC 95%: 0,75-0,87). Los gráficos de CUSUM mostraron una mejora en el rescate de pacientes con complicaciones después del caso 330, pero ninguna mejora en la tasa de casos sin complicaciones hasta el caso 720. (AU)


Assuntos
Humanos , Falha da Terapia de Resgate , Segurança do Paciente , Complicações Pós-Operatórias/mortalidade , Controle de Qualidade
17.
J Clin Pharm Ther ; 46(5): 1220-1225, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33655504

RESUMO

WHAT IS KNOWN AND OBJECTIVE: Postsurgical recovery is influenced by multiple pre-, intra- and perioperative pharmacotherapeutic interventions, including the administration of medications that can induce respiratory depression postoperatively. We present a succinct overview of the topic, including the nature and magnitude of the problem, contributing factors, current limited options, and potential novel therapeutic approach. COMMENT: Pre-, intra- and perioperative medications are commonly administered for anxiety, anaesthesia, muscle relaxation and pain relief among other reasons. Several of the medications alone or in joint-action can be additive or synergistic producing respiratory depression. Given the large number of surgical procedures that are performed each year, even a small percentage of postoperative respiratory complications translates into a large number of affected patients. WHAT IS NEW AND CONCLUSION: Due to the large number of surgeries performed each year, and the variety of medications used before, during, and after surgery, the occurrence of postoperative respiratory depression is surprisingly common. It is a significant medical problem and burden on hospital resources. There is a need for new strategies to prevent and treat the acute and collateral problems associated with postoperative respiratory depression.


Assuntos
Complicações Pós-Operatórias/prevenção & controle , Insuficiência Respiratória/prevenção & controle , Analgésicos/efeitos adversos , Comorbidade , Falha da Terapia de Resgate , Humanos , Hipnóticos e Sedativos/efeitos adversos , Bloqueio Neuromuscular/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Insuficiência Respiratória/induzido quimicamente , Medicamentos para o Sistema Respiratório/uso terapêutico , Medição de Risco , Albumina Sérica/análise
18.
J Vasc Surg ; 74(3): 851-860, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33775748

RESUMO

BACKGROUND: A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals. METHODS: Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue. RESULTS: We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P < .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02). CONCLUSIONS: Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/mortalidade , Falha da Terapia de Resgate , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Complicações Pós-Operatórias/mortalidade , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/tendências , Bases de Dados Factuais , Falha da Terapia de Resgate/tendências , Feminino , Mortalidade Hospitalar/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
19.
Surgery ; 170(3): 863-869, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33707039

RESUMO

BACKGROUND: Failure-to-rescue is a quality indicator measuring the response to postoperative complications. The current study aims to compare failure-to-rescue in patients suffering severe complications after surgery for colorectal cancer between hospitals based on their university status. METHODS: Patients undergoing colorectal cancer surgery from January 2015 to January 2020 in Sweden were included through the Swedish Colorectal Cancer Registry in the current study. Severe postoperative complications were defined as Clavien-Dindo ≥3. Failure-to-rescue incidence rate ratios were calculated comparing university versus nonuniversity hospitals. RESULTS: A total of 23,351 patients were included in this study, of whom 2,964 suffered severe postoperative complication(s). University hospitals had lower failure-to-rescue rates with an incidence rate ratios of 0.62 (0.46-0.84, P = .002) compared with nonuniversity hospitals. There were significantly lower failure-to-rescue rates in almost all types of severe postoperative complications at university than nonuniversity hospitals. CONCLUSION: University hospitals have a lower risk for failure-to-rescue compared with nonuniversity hospitals. The exact mechanisms behind this finding are unknown and warrant further investigation to identify possible improvements that can be applied to all hospitals.


Assuntos
Colectomia/efeitos adversos , Neoplasias Colorretais/cirurgia , Falha da Terapia de Resgate/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Colectomia/estatística & dados numéricos , Feminino , Hospitais/normas , Hospitais Universitários/normas , Humanos , Masculino , Complicações Pós-Operatórias/terapia , Sistema de Registros , Estudos Retrospectivos , Suécia/epidemiologia
20.
J Visc Surg ; 158(4): 317-325, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33736990

RESUMO

Mortality after visceral surgery has decreased owing to progress in surgical techniques, anesthesiology and intensive care. Mortality occurs in 5-10% of patients after major surgery and remains a topic of interest. However, the ratio of mortality after postoperative complications in relation to overall complications varies between hospitals because of failure to rescue at the time of the complication. There are multiple factors that lead to complication-related mortality: they are patient-related, disease-related, but are related, above all, to the timeliness of diagnosis of the complication, the organisational aspects of management in private or public hospitals, hospital volume that corresponds to the centralisation of initial management or to the concept of referral centre in case of complications, to the team spirit, to communication between the health care providers and to the management of the complication itself. Several organisational advances are to be considered, such as the development of shorter hospitalisations and notably ambulatory surgery, as well as enhanced recovery programs. Remote monitoring and the contribution of artificial intelligence must also be evaluated in this context. The reduction of mortality after visceral surgery rests on several tactics: prevention of potentially lethal complications, the all-important reduction of failure to rescue, and risk management before, during and after hospitalisations that are increasingly shorter.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Falha da Terapia de Resgate , Inteligência Artificial , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Mortalidade Hospitalar , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle
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