Variation in Hospital Mortality Associated with Inpatient Surgery

TLDR

Hospital mortality after inpatient surgery varies widely, and reducing postoperative complications—currently a focus of payers and regulators—may lower mortality. The study aimed to determine whether effective management of complications after inpatient general and vascular surgery influences mortality. Researchers ranked hospitals by risk‑adjusted overall mortality into quintiles and then compared complication incidence and death rates among patients with major complications across those quintiles. Mortality varied from 3.5% to 6.9% across quintiles; overall and major complication rates were similar in very‑high and very‑low mortality hospitals, but death among patients with major complications was almost twice as high in very‑high mortality hospitals (21.4% vs 12.5%), indicating that managing complications promptly is key to reducing inpatient surgical mortality.

Abstract

Hospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of complications once they have occurred may be equally important.We studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. We first ranked hospitals according to their risk-adjusted overall rate of death and divided them into five groups. For hospitals in each overall mortality quintile, we then assessed the incidence of overall and major complications and the rate of death among patients with major complications.Rates of death varied widely across hospital quintiles, from 3.5% in very-low-mortality hospitals to 6.9% in very-high-mortality hospitals. Hospitals with either very high mortality or very low mortality had similar rates of overall complications (24.6% and 26.9%, respectively) and of major complications (18.2% and 16.2%, respectively). Rates of individual complications did not vary significantly across hospital mortality quintiles. In contrast, mortality in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low overall mortality (21.4% vs. 12.5%, P<0.001). Differences in rates of death among patients with major complications were also the primary determinant of variation in overall mortality with individual operations.In addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the timely recognition and management of complications once they occur.