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Improving Mortality Following Emergency Surgery In Older Patients Requires Focus On Complication Rescue
Kyle H Sheetz*, Seth A Waits*, Robert W Krell*, Darrell A Campbell, Jr., Michael J Englesbe*, Amir A Ghaferi*
University of Michigan, Ann Arbor, MI

OBJECTIVE(S): Perioperative mortality rates in elderly patients undergoing emergent general/vascular operations vary widely across Michigan hospitals. We hypothesize that a hospital’s ability to rescue older patients from major complications underlies this variation.
METHODS: We identified 23,224 patients undergoing emergent general/vascular surgery procedures at 41 hospitals within the Michigan Surgical Quality Collaborative (MSQC) between 2006-2011. Hospitals were ranked by risk- and reliability-adjusted 30-day mortality and grouped into tertiles. We stratified patients by age (<75 and ≥75). Risk-adjusted major complication and failure to rescue (i.e., mortality following major complication) rates were determined for each tertile of hospital mortality.
RESULTS: Risk-adjusted mortality rates in elderly patients varied 2-fold across all hospitals. Complication rates correlated poorly with mortality. Failure-to-rescue rates, however, were markedly higher in high mortality hospitals (29% lowest tertile vs. 41% highest tertile, p<0.01). When compared to younger patients, overall failure to rescue rates were almost 2-fold greater in the elderly (36.1% ≥75 vs. 18.7% <75, p<0.01).
CONCLUSIONS: Hospitals’ failure to rescue patients from major complications seems to underlie the variation in mortality across Michigan hospitals following emergent surgery. While higher failure to rescue rates in the elderly may signify their diminished physiological reserve for surviving critical illness, the wide variation across hospitals also highlights the importance of systems aimed at the early recognition and effective management of major complications in this vulnerable population.


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