Failure and Rescue in Surgery-Surgical Covenant, Palliative Care, and Reimagining Quality

For Whom the Bell Tolls: Assessing the Incremental Costs Associated With Failure-To-Rescue After Elective Colorectal SurgeryRunning Title: Cost of Failure-To-Rescue After Colorectal Surgery

BACKGROUND

Failure-to-rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. The purpose of this study was to assess the incremental costs of failure-to-rescue after elective colorectal surgery.

METHODS

This was a retrospective study of adult patients identified in the National Inpatient Sample (NIS) from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into four groups: uneventful recovery, successfully rescued, failure-to-rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs.

RESULTS

Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure-to-rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR $12,611-23,116), for the successfully rescued cohort was $42,295 (IQR $27,959-67,077), for the failure-to-rescue cohort was $53,182 (IQR $30,852-95,615), and for the died without attempted rescue cohort was $29,296 (IQR $19-812-45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs compared to the successfully rescued patients for the last three quantiles (fifth quantile (90th percentile): $163,963 vs. $106,521, p<0.001).

DISCUSSION

Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision-making and medical futility and highlight opportunities for resource optimization following postoperative complications.

Variation in the definition of 'failure to rescue' from postoperative complications: a systematic review and recommendations for outcome reporting

BACKGROUND

Failure to rescue is the rate of death amongst patients with postoperative complications and has been proposed as a perioperative quality indicator. However, variation in its definition has limited comparisons between studies. We systematically reviewed all surgical literature reporting failure to rescue rates and examined variations in the definition of the 'numerator,' 'denominator,' and timing of failure to rescue measurement.

METHODS

Databases were searched from inception to 31 December 2022. All studies reporting postoperative failure to rescue rates as a primary or secondary outcome were included. We examined the complications included in the failure to rescue denominator, the percentage of deaths captured by the failure to rescue numerator, and the timing of measurement for complications and mortality.

RESULTS

A total of 359 studies, including 212,048,069 patients, were analyzed. The complications included in the failure to rescue denominator were reported in 295 studies (82%), with 131 different complications used. The median number of included complications per study was 10 (interquartile range 8-15). Studies that included a higher number of complications in the failure-to-rescue denominator reported lower failure-to-rescue rates. Death was included as a complication in the failure to rescue the denominator in 65 studies (18%). The median percentage of deaths captured by the failure to rescue calculation when deaths were not included in the denominator was 79%. Complications (52%) and mortality (40%) were mostly measured in-hospital, followed by 30-days after surgery.

CONCLUSION

Failure to rescue is an important concept in the study of postoperative outcomes, although its definition is highly variable and poorly reported. Researchers should be aware of the advantages and disadvantages of different approaches to defining failure to rescue.

More problems, more money: Identifying and predicting high-cost rescue after colorectal surgery

Background

Successful rescue after elective surgery is associated with increased healthcare costs, but costs vary widely. Treating all rescue events the same may overlook targeted opportunities for improvement. The purpose of this study was to predict high-cost rescue after elective colorectal surgery.

Methods

We identified adult patients in the National Inpatient Sample (2016-2021) who underwent elective colectomy or proctectomy. Rescued patients were defined as those who underwent additional major procedures. Three groups were stratified: 1) uneventful recovery; 2) Low-cost rescue; 3) High-cost rescue. Multivariable Poisson regression was used to identify preoperative clinical predictors of high-cost versus low-cost rescue.

Results

We identified 448,590 elective surgeries, and rescued patients composed 4.8 %(21,635) of the total sample. The median increase in costs in rescued patients was $25,544(p < 0.001). Median total inpatient costs were $95,926 in the most expensive rescued versus $34,811 in the less expensive rescued versus $16,751 in the uneventfully discharged(p < 0.001). When comparing the secondary procedures between the less expensive and most expensive rescued groups, the most expensive had an increased proportion of reoperation (73.4 % versus 53.0 %,p < 0.001). When controlling for other factors and stratification by congestive heart failure due to an interaction effect, a reoperation was independently associated with high-cost rescue (RR with CHF = 3.29,95%CI:2.69-4.04; RR without CHF = 2.29,95%CI:1.97-2.67).

Conclusions

High-cost rescue after colorectal surgery is associated with disproportionately greater healthcare utilization and reoperation. For cost-conscious care, preemptive strategies that reduce reoperation-related complications can be prioritized.

Center-Level Variation in Failure to Rescue After Elective Adult Cardiac Surgery

BACKGROUND

There has been increasing emphasis on evaluation of failure to rescue (FTR) after major inpatient operations. The present study characterized center-level variation in FTR within a national cohort of patients undergoing elective cardiac operations.

METHODS

All adults undergoing elective coronary artery bypass grafting and/or valve operations were identified in the 2016-2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after prolonged mechanical ventilation, stroke, reoperation, acute kidney injury requiring dialysis, sepsis, cardiac arrest or pulmonary embolism. Multi-level, mixed-effects regressions were used to model mortality, complications, and FTR. Centers with high hospital-specific rates of FTR (≥95th percentile) were identified and compared to others.

RESULTS

Of an estimated 454,506 patients included for analysis, 32,537 (7.2%) developed at least 1 complication, and 7669 (1.7%) died before discharge. Overall, 5370 (16.5%) patients experienced FTR. Compared with those who developed ≥1 complication but survived to discharge, FTR patients were significantly older, more commonly female, and had a greater burden of comorbidities as measured by the Elixhauser Comorbidity Index. Risk-adjusted, hospital-specific rates of mortality and FTR were moderately correlated (r = 0.64), mortality and complications were weakly associated (r = 0.16), and complications and FTR exhibited a very weak relationship (r = -0.02). Relative to others, centers with high rates of FTR had lower annual cardiac surgical volume (median 61 [interquartile range 33-133] vs 80 [interquartile range 43-149] cases/y, P = .019).

CONCLUSIONS

The present findings affirm prior work demonstrating a close link between variation in FTR and mortality, but not complications. Further study is necessary to delineate modifiable care pathways that mitigate FTR.

A Predictive Model of Failure to Rescue After Thoracolumbar Fusion

OBJECTIVE

Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients.

METHODS

Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011-2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR.

RESULTS

The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21-25, 1.3 [0.8-2.2]; RAI 26-30, 4.0 [2.4-6.6]; RAI 31-35, 7.0 [3.8-12.7]; RAI 36-40, 10.0 [4.9-20.2]; RAI 41- 45, 21.5 [9.1-50.6]; RAI ≥ 46, 45.8 [14.8-141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89-0.95).

CONCLUSION

Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review

Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.