The difference in mortality rates after lung cancer resection between hospitals with high vs low mortality rates appears to be driven primarily by differences between "failure to rescue" rates, or the rates of death due to a complication after surgery, rather than complication rates themselves, a retrospective cohort study suggests.
The study was published online August 12 in JAMA Surgery.
Overall complications rates were numerically higher in high-mortality hospitals (HMHs), at 23.3%, compared with low-mortality hospitals (LMHs), at 15.6%, but this difference, at an adjusted odds ratio (aOR) of 1.79, was not significant.
There were also no significant differences in the odds of patients experiencing surgical complications when comparing HMHs and LMHs (aOR, 0.73).
However, rates for "failure to rescue" were significantly higher in HMHs, at 25.9%, compared with LMHs, at 8.7% (aOR, 6.55), the investigators report.
The HMHs also had a higher rate of failure to rescue following other medical complications than LMHs (aOR, 15.39).
"We know that a wide variation in mortality rates exists across both hospitals and surgeons, suggesting that we have the ability to improve the safety of cancer surgery," senior author Sandra Wong, MD, Center for Healthcare Outcomes and Policy, University of Michigan, in Ann Arbor, said in an author podcast posted on the JAMA Surgery website.
"So we specifically picked a group of hospitals with very high mortality rates and a group of hospitals with very low mortality rates, and we looked at rates of adherence to perioperative processes of care, the incidence of complications, and failure-to-rescue rates following complications for lung cancer resection," she explained.
"And while we found that there was some variation in rates of adherence to processes of care and that the incidence of complications was slightly higher in the very-high-mortality hospitals group, these differences were not statistically significant."
"But what was really interesting was that case fatality rates, or failure-to-rescue rates, were significantly higher in the HMHs compared to the LMHs, so the major difference in mortality [between HMHs and LMHs] was due to the concept of failure to rescue," she said.
Study Details
For their study, the investigators used the National Cancer Data Base, a hospital-based registry that accounts for approximately 70% of all cancers diagnosed in the United States.
The team reviewed on-site medical records at participating institutions from January 2, 2006, through December 31, 2007, and identified 645 patients with lung cancer for their study. Of these, 441 patients were treated in LMHs, and 204 were treated in HMHs.
"Patients who underwent lung cancer resection at HMHs presented with greater illness severity compared with those who were treated at LMHs," investigators observe.
A greater proportion of patients at HMHs also had poorer functional status on presentation, at 7.8%, compared with patients treated at LMHs, at 1.6% (P < .001).
Patients who were treated at HMHs were more likely to have more than two comorbid conditions (24% compared with 15.9% of those treated at LMHs; P = .01).
Specifically, these comorbidities included a higher proportion of patients with ischemic heart disease (22.5% in HMHs vs 14.1% in LMHs; P = .007) and diabetes (18.6% in HMHs vs 11.3% in LMHs; P = .01).
HMHs also performed a significantly higher percentage of emergency procedures (2.5% vs 0.2% at LMHs; P = .006).
Prior to risk adjustment, the overall mortality rate at LMHs was 1.6%, compared with 10.8% for HMHs (P < .001).
After risk adjustment, these differences were attenuated, but mortality rates were still considerably different, at 1.8% at LMHs vs 8.1% at HMHs (P < .001), the investigators add.
Different Operative Approaches
There were some, although often not significant, differences in operative approaches taken by high- vs low-mortality hospitals.
For example, adjusting for patient factors and cancer state, patients treated at an HMH were more than three times as likely to undergo an open thoracotomy compared with LMH patients (aOR, 3.15) and 69% less likely to undergo a thoracoscopic lung resection than those at an LMH (aOR, 0.31).
HMHs were also 82% less likely to use intraoperative monitoring (aOR, 0.16) compared with LMHs.
HMHs were also more than 4.5 times as likely to continue giving prophylactic antibiotics for longer than 24 hours after surgery than LMHs (aOR, 4.69), and they were also 90% to 94% less likely to use either chemoprophylaxis or sequential-compression devices, either preoperatively or in the postoperative setting (aOR, 0.10 and 0.06, respectively).
"If we are to really look at reducing mortality rates, one of the main things to focus on would be the earlier and more efficient identification of complications and acting on that in a more rapid fashion in order to save patients," Dr Wong said.
"And this study, while focusing on lung cancer, is just one example of how this concept probably applies across the board and which would likely be similar across different types of procedures."
The study was supported by grants from the Agency for Healthcare Research and Quality and from the National Cancer Institute. Dr Wong has disclosed no relevant financial relationships.
JAMA Surg. Published online August 12, 2015. Full text
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