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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. This study aimed 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 from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 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 than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001)., Conclusion: 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 after postoperative complications., (Published by Elsevier Inc.)

Objective: To determine the relationship between volume of cases and failure-to-rescue (FTR) rate after surgery for acute type A aortic dissection (ATAAD) across the United States., Methods: The Society of Thoracic Surgeons adult cardiac surgery database was used to review outcomes of surgery after ATAAD between June 2017 and December 2021. Mixed-effect models and restricted cubic splines were used to determine the risk-adjusted relationships between ATAAD average volume and FTR rate. FTR calculation was based on deaths associated with the following complications: venous thromboembolism/deep venous thrombosis, stroke, renal failure, mechanical ventilation >48 hours, sepsis, gastrointestinal complications, cardiopulmonary resuscitation, and unplanned reoperation., Results: In total, 18,192 patients underwent surgery for ATAAD in 832 centers. The included hospitals' median volume was 2.2 cases/year (interquartile range [IQR], 0.9-5.8). Quartiles' distribution was 615 centers in the first (1.3 cases/year, IQR, 0.4-2.9); 123 centers in the second (8 cases/year, IQR, 6.7-10.2); 66 centers in the third (15.6 cases/year, IQR, 14.2-18); and 28 centers in the fourth quartile (29.3 cases/year, IQR, 28.8-46.0). Fourth-quartile hospitals performed more extensive procedures. Overall complication, mortality, and FTR rates were 52.6%, 14.2%, and 21.7%, respectively. Risk-adjusted analysis demonstrated increased odds of FTR when the average volume was fewer than 10 cases per year., Conclusions: Although high-volume centers performed more complex procedures than low-volume centers, their operative mortality was lower, perhaps reflecting their ability to rescue patients and mitigate complications. An average of fewer than 10 cases per year at an institution is associated with increased odds of failure to rescue patients after ATAAD repair., Competing Interests: Conflict of Interest Statement I.S. and D.S.G. report institutional research support from Abbott, Medtronic, Boston Scientific, CryoLife, and AtriCure (none relevant). W.Y.S. reports Edwards Lifesciences, Medtronic, Artivion, Terumo Aortic, Abbott: investigator, speaker, advisory board. D.C. reports Sanamedi, Inc: proctor, consultant; and The Osler Institute: faculty. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs)., Methods: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR., Results: Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001)., Conclusions: Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The role and impact of preoperative chemotherapy (PC) in pancreatic adenocarcinoma are questions under active investigation. Here we investigate the rate of failure to rescue (FTR) and surgical outcomes in patients undergoing pancreatectomy, with PC within 90 days (d) prior to surgery and without PC., Materials and Methods: The National Surgical Quality Improvement Program Targeted Dataset for Pancreatectomy (2014-2020) was queried to identify patients who underwent pancreatectomy for malignant non-neuroendocrine pancreatic tumors. The cohort was divided into those who underwent PC within 90 d and those without. Propensity score analysis was employed to match patients 1:1 based on age, sex, body mass index, hypertension, smoking status, ascites, diabetes, and American Society of Anesthesiology (ASA) score. The primary outcome of interest was FTR, defined as mortality following a major complication (Clavien-Dindo Class III-V)., Results: After propensity score matching, 7895 patients with PC were matched to 7895 patients without PC. PC patients exhibited a significantly lower rate of FTR (P = 0.002) despite having higher ASA scores. This benefit was most pronounced in the pancreaticoduodenectomy subgroup (P < 0.009). PC patients demonstrated a lower rate of overall complications compared to those without PC (P < 0.001). Overall, the PC group was more likely to require vascular resection (P < 0.001)., Conclusions: Patients who received chemotherapy within 90 d prior to surgery experienced a lower rate of FTR and overall complications despite higher ASA scores and incidence of vascular resection. This suggests that, when appropriate, the receipt of PC does not negatively impact surgical outcomes., (Copyright © 2024. Published by Elsevier Inc.)

Background: Failure to rescue (FTR), defined as death after a major complication, is increasingly being used as a surrogate for assessing quality of care following major cancer resection. The aim of this paper is to determine the failure to rescue (FTR) rate after oesophagectomy and explore factors that may contribute to FTR within Australia., Methods: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2023 at five Australian hospitals was conducted to identify patients who underwent an oesophagectomy. The primary outcome was FTR rate. Perioperative parameters were examined to evaluate predictive factors for FTR. Secondary outcomes include major complications, overall morbidity, mortality, length of stay and 30-day readmissions., Results: A total of 155 patients were included with a median age of 65.2 years, 74.8% being male. The FTR rate was 6.3%. In total, 50.3% of patients (n = 78) developed at least one postoperative complication with the most common complication being pneumonia (20.6%) followed by prolonged intubation (12.9%) and organ space SSI/anastomotic leak (11.0%). Multivariate logistic regression analysis was performed to determine any factors that were predictive for FTR however none reached statistical significance., Conclusion: This study is the first to evaluate the FTR rates following oesophagectomy within Australia, with FTR rates and complication profile comparable to international benchmarks. Integration of multi-institutional national databases such as ACS NSQIP into units is essential to monitor and compare patient outcomes following major cancer surgery, especially in low to moderate volume centres., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Introduction: We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR., Methods: A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression., Results: Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR., Discussion: Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Complications are associated with postoperative mortality and readmission. However, the timing of complications relative to discharge and the extent to which timing is associated with failure to rescue (FTR) and readmission after pediatric surgery is unknown. Our goal was to describe the timing of complications relative to discharge after inpatient pediatric surgery and determine the association between complication timing, FTR, and unplanned readmission., Materials and Methods: National cohort study of patients within the NSQIP-Pediatric database who underwent inpatient surgery (2012-2019). Complications were categorized based on when they occurred relative to discharge: only pre-discharge, only post-discharge, both. The association between perioperative outcomes and the timing of postoperative complications was evaluated with multivariable hierarchical regression., Results: Among 378,551 patients, 30,213 (8.0%) had at least one postoperative complication. Relative to patients with pre-discharge complications, post-discharge complications were associated with significantly decreased odds of FTR (odds ratio 0.21, 95% confidence interval [0.15-0.28]) and significantly increased odds of readmission (odds ratio 19.37 [17.93-20.92]). Odds of FTR and readmission in patients with complications occurring both before and after discharge were similar to that of patients with only post-discharge complications., Conclusions: FTR and readmission are associated with complications occurring at different times relative to discharge (FTR primarily pre-discharge; readmission primarily post-discharge). This suggests a 'one size fits all' approach to surgical quality improvement may not be effective and different approaches are needed to address different quality indicators., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Surgical stabilization of rib fractures (SSRF) has been associated with lower rates of mortality and fewer respiratory complications. This study sought to evaluate the association between SSRF timing and patient outcomes., Methods: This retrospective analysis included patients aged ≥45 y who underwent SSRF in the Trauma Quality Improvement Program database from 2016 to 2020. Primary outcome was incidence of ventilator-assisted pneumonia (VAP). Secondary outcomes included acute respiratory distress syndrome (ARDS), unplanned endotracheal intubation, in-hospital mortality, failure to rescue (FTR) after all major complications, and FTR after severe respiratory complications. Logistic regression models of outcomes on timing to SSRF were fit while controlling for age, gender, body mass index, injury severity score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking., Results: Among 4667 patients who received SSRF, average time to SSRF was 4.6 ± 3.2 d. Each additional day to SSRF was associated with increased odds of VAP (odds ratio [OR] 1.07, confidence interval [CI] 1.03-1.11) and intubation (OR 1.10, CI 1.08-1.13). A longer time to SSRF was associated with increased odds of ARDS (OR 1.10, CI 1.05-1.15), while no significant association was observed for in-hospital mortality (OR 0.99, CI 0.93-1.04). A longer time to SSRF was associated with decreased odds of FTR after a major complication (OR 0.90, CI 0.83-0.97) and respiratory complications (OR 0.87, CI 0.78-0.96)., Conclusions: For each day that SSRF is delayed, increased odds of VAP, intubation, and ARDS were observed. Prompt intervention is crucial for preventing these complications and improving our ability to rescue patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Failure to rescue, or the death of a patient after a surgical complication, largely occurs in patients who develop a cascade of postoperative complications. However, it is unclear whether there are specific types of index complications that are more strongly associated with failure to rescue, additional secondary complications, or other types of postoperative outcomes. This is a national cohort study of veterans who underwent noncardiac surgery at Veterans Affairs hospitals using data from the Veterans Affairs Surgical Quality Improvement Program (January 1, 2016 to September 30, 2021). Index complications were grouped into categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, sepsis, Clostridium difficile colitis, graft, or minor [defined as complications having an associated mortality rate <1%]). The association between type of index complication and failure to rescue, secondary complications, reoperation, and postoperative length of stay was evaluated with multivariable, hierarchical regression, and risk of death assessed with shared frailty modeling., Results: Among 574,195 patients, 5.3% had at least 1 complication (of which 26.1% had secondary complications, and 8.2% had failure to rescue), and 4.5% had a reoperation. Secondary complication (5.0%-61.4%) and failure to rescue (0.8%-34.2%) rates varied by the type of index complication. Relative to index minor complications, index bleeding was most associated with secondary complication (subdistribution hazard ratio 1.4, 95% confidence interval [1.1-1.8]), index cardiac complications were most associated with failure to rescue (odds ratio 45.4 [34.5-59.7]), index graft complications were most associated with reoperation (odds ratio 96.0 [79.5-115.8]), and index pulmonary complications were associated with 2.6 times longer length of stay (incident rate ratio 2.6 [2.6-2.7]). Index cardiac and central nervous system complications were most strongly associated with risk of death (cardiac-hazard ratio 2.45, 95% confidence interval [2.14-2.81]; central nervous system-hazard ratio 1.84 [1.49-2.27])., Conclusion: Different types of index complications are associated with different outcome profiles. This suggests surgical quality improvement efforts should be tailored not only to the type of index complication to be addressed but also to the desired outcome to improve., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The association between procedural volume and esophagectomy outcomes has been established, but the relationship between higher levels of care and esophagectomy outcomes has not been explored. This study aims to investigate whether hospital participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) esophagectomy-targeted registry is associated with superior outcomes., Methods: The 2016-2020 ACS NSQIP standard and esophagectomy-targeted registries were queried. Esophagectomy outcomes were analyzed overall and stratified by esophagectomy type (Ivor Lewis vs. transhiatal vs. 3-field McKeown)., Results: A total of 2181 and 5449 esophagectomy cases were identified in the standard and targeted databases (68% Ivor Lewis esophagectomy). The median age was 65 years and 80% were male. Preoperative characteristics were largely comparable. On univariate analysis, targeted hospitals were associated with lower mortality (2% vs. 4%, p < 0.01) and failure-to-rescue rates (11% vs. 17%, p < 0.01), higher likelihood of an optimal outcome (62% vs. 58%, p = 0.01), and shorter hospital stay (median 9 vs. 10 days, p < 0.01). On multivariable analysis, Ivor Lewis esophagectomy at targeted centers was associated with reduced odds of mortality [odds ratio (OR) 0.57 and 95% confidence intervals 0.35-0.90] and failure-to-rescue [OR 0.54 (0.33-0.90)] with no difference in serious morbidity or optimal outcome. There was no statistically significant difference in odds of mortality or failure to rescue in targeted versus standard centers when performing transhiatal or McKeown esophagectomy., Conclusions: Esophagectomy performed at hospitals participating in the targeted ACS NSQIP is associated with roughly half the risk of mortality compared to the standard registry. The factors underlying this relationship may be valuable in quality improvement., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: The impact of hospital procedural volume on outcomes after hepatectomy relative to other facility-related factors remains unclear. We sought to define the comparative impact of hospital volume compared with other facility-related factors on postoperative outcomes among Medicare beneficiaries undergoing hepatectomy., Methods: Data on patients who underwent hepatectomy between 2013 and 2021 were collected from the Medicare Standard Analytic Files and linked with facility-level data from the American Hospital Association Survey databases. Hospital volume was stratified into high- (top 10%) and low-volume centers. Propensity score matching was used to account for variable imbalances in patient characteristics among high-compared with low-volume centers. Mediation analysis was employed to delineate facility-related factors responsible for the impact of hospital volume on outcomes with a specific focus on incidence of complications, in-hospital mortality, and failure to rescue., Results: The analytic cohort included 22,969 patients from 340 institutions. After propensity score matching, receipt of surgery at a high-volume center was associated with a lower likelihood of postoperative complications (39.9% vs 41.7%, P = .01), in-hospital mortality (2.2% vs 2.8%, P = .02), and failure to rescue (5.4% vs 6.5%, P = .04) versus low-volume centers. Mediation analysis revealed that hospital capacity (bed capacity and nurse-to-bed ratio) contributed the most to the variations in risk of complications and in-hospital mortality, whereas liver transplant program status had the largest impact on failure to rescue., Conclusions: Hospital volume is a significant determinant of postoperative outcomes after hepatectomy, with hospital capacity and liver transplant program status being important mediators of this effect. Centralization and optimal resource distribution are important to achieve favorable outcomes following liver resection., Competing Interests: Conflicts of interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR., Methods: Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year., Results: A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001)., Conclusions: Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The differentiators of centers performing at the highest level of quality and patient safety are likely both structural and cultural. We aimed to combine five indicators representing established domains of trauma quality and to identify and describe the structural characteristics of consistently performing centers., Methods: Using American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2020, we evaluated five quality measures across several care domains for adult patients in levels I and II trauma centers: (1) time to operating room for patients with abdominal gunshot wounds and shock, (2) proportion of patients receiving timely venous thromboembolism prophylaxis, (3) failure to rescue (death following a complication), (4) major hospital complications, and (5) mortality. Overall performance was summarized as a composite score incorporating all measures. Centers were ranked from highest to lowest performer. Principal component analysis showed the influence of each indicator on overall performance and supported the composite score approach., Results: We identified 272 levels I and II centers, with 28 and 27 centers in the top and bottom 10%, respectively. Patients treated in high-performing centers had significant lower rates of death major complications and failure to rescue, compared with low-performing centers ( p < 0.001). The median time to operating room for gunshot wound was almost half that in high compared with low-performing centers, and rates of timely venous thromboembolism prophylaxis were over twofold greater ( p < 0.001). Top performing centers were more likely to be level I centers and cared for a higher number of severely injured patients per annum. Each indicator contributed meaningfully to the variation in scores and centers tended to perform consistently across most indicators., Conclusion: The combination of multiple indicators across dimensions of quality sets a higher standard for performance evaluation and allows the discrimination of centers based on structural elements, specifically level 1 status, and trauma center volume., Level of Evidence: Therapeutic /Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pancreaticoduodenectomy serves as the standard surgical treatment for periampullary tumors. Previous studies have suggested that high body mass index (BMI) is associated with an unfavorable prognosis following laparoscopic pancreaticoduodenectomy (LPD). However, the relationship between low BMI and postoperative complications remains unclear. Materials and Methods: A retrospective analysis of clinical data from 1130 patients who underwent LPD between April 2014 and December 2022 was conducted. Multivariate regression and restricted cubic spline analyses were utilized to explore the correlations between BMI and short-term outcomes, with adjustments for potential confounders. Results: Multivariable logistic regression revealed that overweight, obese, or severely underweight patients had an elevated risk of postoperative pancreatic fistula (POPF) compared to those with a normal BMI. Moreover, obesity was significantly correlated with a higher proportion of "failure to rescue." BMI exhibited a J-shaped relationship with respiratory complications and in-hospital mortality, a W-shaped relationship with multiple complications and anastomotic leakage (pancreatic fistula), and a U-shaped association with "failure to rescue" rates. The lowest risk was observed at BMI levels of 20 and 25 kg/m 2 for multiple complications and pancreatic fistula, respectively. Conclusion: Both high and low BMI are identified as risk factors for the occurrence of postoperative POPF and in-hospital mortality following LPD. Notably, patients with higher BMI and severe underweight conditions are associated with an increased likelihood of "failure to rescue."

Background: Failure-to-rescue (FTR), defined as death following a major complication, is a metric of trauma quality. The impact of patient frailty on FTR has not been fully investigated, especially in geriatric trauma patients. This study hypothesized that frailty increased the risk of FTR in geriatric patients with severe injury., Methods: A retrospective cohort study was conducted using the TQIP database between 2015 and 2019, including geriatric patients with trauma (age ≥65 years) and an Injury Severity Score (ISS) > 15, who survived ≥48 hours postadmission. Frailty was assessed using the modified 5-item frailty index (mFI). Patients were categorized into frail (mFI ≥ 2) and nonfrail (mFI < 2) groups. Logistic regression analysis and a generalized additive model (GAM) were used to examine the association between FTR and patient frailty after controlling for age, sex, type of injury, trauma center level, ISS, and vital signs on admission., Results: Among 52,312 geriatric trauma patients, 34.6% were frail (mean mFI: frail: 2.3 vs. nonfrail: 0.9, p < 0.001). Frail patients were older (age, 77 vs. 74 years, p < 0.001), had a lower ISS (19 vs. 21, p < 0.001), and had a higher incidence of FTR compared with nonfrail patients (8.7% vs. 8.0%, p = 0.006). Logistic regression analysis revealed that frailty was an independent predictor of FTR (odds ratio, 1.32; confidence interval, 1.23-1.44; p < 0.001). The GAM plots showed a linear increase in FTR incidence with increasing mFI after adjusting for confounders., Conclusion: This study demonstrated that frailty independently contributes to an increased risk of FTR in geriatric trauma patients. The impact of patient frailty should be considered when using FTR to measure the quality of trauma care., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 American Association for the Surgery of Trauma.)

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., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries., Methods: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding., Results: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score., Conclusion: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery., (© 2024. The Author(s).)

Background: More than 700 hospitals participate in the American College of Surgeons National Surgical Quality Improvement Program, but most pancreatectomies are performed in 165 centers participating in the pancreas procedure-targeted registry. We hypothesized that these hospitals ("targeted hospitals") might provide more specialized care than those not participating ("standard hospitals")., Methods: The 2014 to 2019 pancreas-targeted and standard American College of Surgeons National Surgical Quality Improvement Program registry were reviewed regarding patient demographics, comorbidities, and perioperative outcomes using standard univariate and multivariable logistic regression analyses. Primary outcomes included 30-day mortality and serious morbidity., Results: The registry included 30,357 pancreatoduodenectomies (80% in targeted hospitals) and 14,800 distal pancreatectomies (76% in targeted hospitals). Preoperative and intraoperative characteristics of patients treated at targeted versus standard hospitals were comparable. On multivariable analysis, pancreatoduodenectomies performed at targeted hospitals were associated with a 39% decrease in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.50-0.75), 17% decrease in serious morbidity (odds ratio, 0.83; 95% confidence interval, 0.77-0.89), and 41% decrease in failure-to-rescue (odds ratio, 0.59; 95% confidence interval, 0.47-0.74). These differences did not apply to distal pancreatectomies. Participation in the targeted registry was associated with higher rates of optimal surgery for both pancreatoduodenectomy (odds ratio, 1.33; 95% confidence interval, 1.25-1.41) and distal pancreatectomy (odds ratio, 1.17; 95% confidence interval, 1.06-1.30)., Conclusion: Mortality and failure-to-rescue rates after pancreatoduodenectomy in targeted hospitals were nearly half of rates in standard American College of Surgeons National Surgical Quality Improvement Program hospitals. Further research should delineate factors underlying this effect and highlight opportunities for improvement., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020. Published by Elsevier Inc.)

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.

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., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2021 The Korean Academy of Medical Sciences.)

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.

Background: For many cancer resections, a hospital volume-outcome relationship exists. The data regarding gastric cancer resection-especially in the western hemisphere-are ambiguous. This study analyzes the impact of gastric cancer surgery caseload per hospital on postoperative mortality and failure to rescue in Germany., Methods: All patients diagnosed with gastric cancer from 2009 to 2017 who underwent gastric resection were identified from nation-wide administrative data. Hospitals were grouped into five equal caseload quintiles (I-V in ascending caseload order). Postoperative deaths and failure to rescue were determined., Results: Forty-six thousand one hundred eighty-seven patients were identified. There was a significant shift from partial resections in low-volume hospitals to more extended resections in high-volume centers. The overall in-house mortality rate was 6.2%. The crude in-hospital mortality rate ranged from 7.9% in quintile I to 4.4% in quintile V, with a significant trend between volume categories (p < 0.001). In the multivariable logistic regression analysis, quintile V hospitals (average of 29 interventions/year) had a risk-adjusted odds ratio of 0.50 (95% CI 0.39-0.65), compared to the baseline in-house mortality rate in quintile I (on average 1.5 interventions/year) (p < 0.001). In an analysis only evaluating hospitals with more than 30 resections per year mortality dropped below 4%. The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue (FtR) decreased significantly with increasing caseload., Conclusion: Patients who had gastric cancer surgery in hospitals with higher volume had better outcomes and a reduced failure to rescue rates for severe complications.

Background: Colectomies are common yet costly, with high surgical-site infection rates. Safety-net hospitals (SNHs) carry a large proportion of uninsured or Medicaid-insured patients, which has been associated with poorer surgical outcomes. Few studies have examined the effect of safety-net burden (SNB) status on colectomy outcomes. We aimed to quantify the independent effects of hospital SNB and surgical site infection (SSI) status on colectomy outcomes, as well as the interaction effect between SSIs and SNB., Methods: We used the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky. We included 459,568 colectomies (2009 to 2014) for analysis, excluding patients age <18 y and rectal cases. The primary and secondary outcomes were inpatient mortality and complications, respectively., Results: Adjusting for patient, procedure, and hospital factors, colectomy patients were more likely to die in-hospital at high-burden SNHs (adjusted OR [aOR]: 1.38, 95% confidence interval [CI]: 1.25-1.51, P < 0.001), compared with low SNB hospitals and to experience perioperative complications (aOR: 1.12, 95% CI: 1.04-1.20, P < 0.01). Colectomy patients with SSIs also had greater odds of in-hospital mortality (aOR: 1.92, 95% CI: 1.83-2.02, P < 0.001) and complications (aOR: 3.65, 95% CI: 3.55-3.75, P < 0.001) compared with those without infections. Patients treated at SNHs who developed a SSI were even more likely to have an additional perioperative complication (aOR: 4.33, 95% CI: 3.98-4.71, P < 0.001)., Conclusions: Our study demonstrated that colectomy patients at SNHs have poorer outcomes, and for patients with SSIs, this disparity was even more pronounced in the likelihood for a complication. SNB should be recognized as a significant hospital-level factor affecting colectomy outcomes, with SSIs as an important quality metric., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi., Methods: We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality., Results: We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation., Conclusions: Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Pulmonary complications are the most common adverse event after injury and second greatest cause of failure to rescue (death after pulmonary complications). It is not known whether readily accessible trauma center data can be used to stratify center-level performance for various complications. Performance variation between trauma centers would allow sharing of best practices among otherwise similar hospitals. We hypothesized that high-, average-, and low-performing centers for pulmonary complication and failure to rescue could be identified and that hospital factors associated with success and failure could be discovered., Methods: Pennsylvania state trauma registry data (2007-2015) were abstracted for pulmonary complications. Burns and age <17 were excluded. Multivariable logistic regression models were developed for pulmonary complication and failure to rescue, using demographics, comorbidities, and injuries/physiology. Expected event rates were compared with observed rates to identify outliers. Center-level variables associated with outcomes of interest were taken from the American Hospital Association Annual Survey Database and assessed for inclusion., Results: Included in the study were 283,121 patients (male [60%] blunt trauma [92%]). Of these patients, 3% (8,381 of 283,121) developed pulmonary complications (center-level range 0.18%-5.8%). The percentage of failure-to-rescue patients was 13.4% (1,120/8,381, center-level range 0.0%-22.6%). For pulmonary complications, 13 out of 27 centers were high performers (95% CI for O:E ratio <1) and 7 out of 27 were low (95% CI for an O:E ratio >1). For failure-to-rescue patients, 2 out of 27 centers were low performers and the remainder average. There was little concordance between performance for pulmonary complications and failure to rescue. Research programs, large non-teaching hospitals, those with advanced practice providers, and those with health maintenance organizations had reduced failure-to-rescue patients., Conclusion: Factors associated with complications were distinct from those affecting failure to rescue and center-level success in reducing complications often did not translate into success in preventing death once they occurred. Our data demonstrate that high- and low-performing centers and the factors driving success or failure are identifiable. This work serves as a guide for comparing practices and improving outcomes with readily available data., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This article provides a better understanding of how interactions and relationships within hospital microsystems affect rescue. Through structured engagement of clinical champions, these rescue improvement tools may decrease rates of secondary and tertiary complications and enhance staff culture, confidence, and competence. The proposed 3-prong approach sheds light on how health care organizations can better sense, cope with, and respond to the unexpected and changing demands presented by clinically deteriorating postsurgical patients. These interventions lay the groundwork for the further development, testing, and implementation of larger scale rescue-focused initiatives, which could have a direct, population-level impact on mortality., Competing Interests: Disclosure This research is funded through grants from the Patient-Centered Outcomes Research Institute (PCORI), the Agency for Healthcare Research and Quality (AHRQ), and the National Institutes of Health (NIH). Dr A.A. Ghaferi also receives salary support from Blue Cross Blue Shield of Michigan as the Director of the Michigan Bariatric Surgery Collaborative., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Failure to rescue (FTR) is gaining popularity as a quality metric. The relationship between patient frailty and FTR after cardiovascular surgery has not been fully explored. This study aimed to utilize a national database to examine the impact of patient frailty on FTR., Methods: Of 5,199,534 patients undergoing cardiovascular surgery between 2000 and 2014, 75,851 (1.5%) were identified from the Nationwide Inpatient Sample database as frail based on the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Propensity-score matching was used to adjust for patient- and hospital-level characteristics and comorbidities when comparing frail and nonfrail patients., Results: Frail patients were on average older (68 ± 12 years vs 65 ± 12 years; P < .001) and had more comorbidities including heart failure, and chronic lung, liver, or renal disease. Among 68,472 matched pairs, frail patients had significantly higher rates of FTR (13.4% vs 11.9%; P < .001). This contributed to a $39,796 increase in cost per hospitalization (P < .001). Renal failure, respiratory failure, pneumonia, and sepsis were most commonly associated with FTR in frail patients. When hospitals were stratified by risk-adjusted mortality, low-mortality (1st quintile) centers had significantly lower FTR rates and costs among frail patients when compared to high-mortality (5th quintile) centers., Conclusions: Frailty contributes significantly to FTR after cardiovascular surgery. Frail patients can expect better outcomes with lower costs at cardiac surgical centers of excellence that can adequately manage postoperative outcomes. Preoperative assessment of frailty may better guide risk estimation and identification of patients who would benefit from appropriate prehabilitative interventions to optimize outcomes., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Socially stigmatized preexisting conditions (SSPECs), including alcohol use disorder (AUD), drug use disorder (DUD), and major psychiatric illness, may lead to provider minimization of patient symptoms and have been associated with negative outcomes. However, the impact of SSPECs on failure to rescue (FTR) has not been evaluated. We hypothesized that SSPEC patients would have increased probability of complications, mortality, and FTR., Materials and Methods: We performed a retrospective analysis of the 2015 National Trauma Data Bank, including patients aged ≥18 y and excluding burn victims, patients with Injury Severity Score <9, and non-SSPEC patients with drug or alcohol withdrawal. We defined SSPECs using the National Trauma Data Bank's comorbidity recording codes for AUD, DUD, and major psychiatric illnesses. We built multivariable logistic regression models to determine the relationships between SSPECs and complications, mortality, and FTR., Results: We included 365,801 patients (62% male, 76% White, median age 56 y [interquartile range 35-74], median Injury Severity Score 10 [interquartile range 9-17]). After adjusting for patient and injury characteristics, SSPEC patients were more likely to have complications (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.70-1.79), less likely to die (OR 0.43, CI 0.38-0.48), and less likely to have FTR (OR 0.34, CI 0.26-0.43). SSPEC patients had a significantly higher complication rate (12.4% versus 7.2%; P < 0.001). After excluding drug or alcohol withdrawal, the complication rate remained significantly higher for SSPEC patients (9.3% versus 7.2%; P < 0.001)., Conclusions: Although SSPEC patients have lower odds of mortality and FTR, they are at higher probability of complications after injury. Further investigation into the causality behind the higher complications despite lower mortality and FTR is warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Administrative data research on maternal racial disparities supports 2 broad clinical inferences. First, failure to rescue in terms of both death and severe maternal morbidity likely accounts for a significant proportion of maternal disparities. Second, risk for adverse outcomes by race is generally differential with risk for cardiovascular complications particularly high for non-Hispanic black women. These differentials suggest that underlying health conditions may represent an important contributor to overall disparities, and optimal longitudinal care utilization with nonobstetric specialists is required to mitigate risk., Competing Interests: Disclosures Dr. Friedman is supported by the Health Resources and Services Administration Maternal and Child Health Bureau (R40 MC3287901)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The maternal mortality ratio in the United States is increasing; understanding the significance of this change and developing effective responses requires a granular analysis of the contributing factors that a well-informed maternal mortality review committee can provide. Data collection and analysis, clinical factors, preventability, social determinants of health, and racial inequities combine to affect this outcome, and each factor must be considered individually and in combination to recommend a robust response. Obstetrician-gynecologists formed the State of Michigan's Maternal Mortality Review Committee (the Committee) in 1950 to identify gaps in care that needed to be systematically addressed at the time. In the early years, the Committee witnessed a reduction in the number of maternal deaths; over time, prioritization of maternal mortality decreased, yet the Committee witnessed changing patterns of death, varied data collection and evaluation processes, delayed reviews, and unimplemented recommendations. The calculation of the maternal mortality ratio was not informed by the outcomes of Committee reviews. Today, the Committee, with increased support from the Michigan Department of Health & Human Services, can clearly identify and report preventable pregnancy-related mortality along with its causes and is close to achieving a near real-time surveillance system that allows the development of timely clinical and policy recommendations and interventions. The Committee's adaptations in response to the rise in maternal mortality have resulted in several lessons learned that may be helpful for currently operating committees and in the formation of new ones.

Objective: To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation)., Methods: Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend., Results: From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08)., Conclusion: After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.

Background: We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume., Methods: Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden., Results: Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume., Conclusion: Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery., Competing Interests: Declarations of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma., Methods: We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR., Results: A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications., Conclusions: Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly., Level of Evidence: Level III Prognostic., (Copyright © 2020. Published by Elsevier Inc.)

Background: Failure to Rescue (FTR) is a valuable surgical quality improvement metric. The aim of this study is to assess the relationship between center volume and FTR following lung transplantation., Methods: Using the database of the United Network for Organ Sharing (UNOS) all adult, primary, isolated lung recipients in the United States between May 2005 and March 2016 were identified. FTR was defined as operative mortality after any of five specific complications. FTR was compared across terciles of transplantation centers stratified based on operative volume., Results: 17,185 lung recipients met study criteria. The composite FTR rate (Death following at least one complication) was 20.7%. Following stratification by volume, FTR rates increased from high to middle tercile centers (19.3% vs. 23.0%). Multivariate logistic regression models suggested an independent relationship between higher center volume and lower FTR rates (p < 0.001)., Conclusion: Higher volume lung transplantation centers have lower rates of failure to rescue., Competing Interests: Declaration of competing interest Authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Recent observational studies on volume-outcome associations in hepatobiliary surgery were not designed to account for the varying extent of hepatobiliary resections and the consequential risk of perioperative morbidity and mortality. Therefore, this study aimed to determine the risk-adjusted in-hospital mortality for minor and major hepatobiliary resections at the national level in Germany and to examine the effect of hospital volume on in-hospital mortality, and failure to rescue., Methods: All inpatient cases of hepatobiliary surgery (n = 31,114) in Germany from 2009 to 2015 were studied using national hospital discharge data. After ranking hospitals according to increasing hospital volumes, five volume categories were established based on all hepatobiliary resections. The association between hospital volume and in-hospital mortality following minor and major hepatobiliary resections was evaluated by multivariable regression methods., Results: Minor hepatobiliary resections were associated with an overall mortality rate of 3.9% and showed no significant volume-outcome associations. In contrast, overall mortality rate of major hepatobiliary resections was 10.3%. In this cohort, risk-adjusted in-hospital mortality following major resections varied widely across hospital volume categories, from 11.4% (95% CI 10.4-12.5) in very low volume hospitals to 7.4% (95% CI 6.6-8.2) in very high volume hospitals (risk-adjusted OR 0.59, 95% CI 0.41-0.54). Moreover, rates of failure to rescue decreased from 29.38% (95% CI 26.7-32.2) in very low volume hospitals to 21.38% (95% CI 19.2-23.8) in very high volume hospitals., Conclusions: In Germany, patients who are undergoing major hepatobiliary resections have improved outcomes, if they are admitted to higher volume hospitals. However, such associations are not evident following minor hepatobiliary resections. Following major hepatobiliary resections, 70-80% of the excess mortality in very low volume hospitals was estimated to be attributable to failure to rescue.

Introduction: We tested whether frail patients may benefit from robot-assisted (RARC) relative to open radical cystectomy (ORC)., Materials and Methods: Frail patients treated with RC were identified within the National Inpatient Sample database (2008-2015). The effect of RARC vs. ORC was tested in five separate multivariable models predicting: complications, failure to rescue (FTR), in-hospital mortality, length of stay (LOS) and total hospital charges (THCs). As internal validity measure, analyses were repeated among non-frail patients. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics., Results: Of 11,578 RC patients, 3477 (30.0%) were frail. RARC was performed in 488 (14.0%) frail patients and 1386 (17.1%) non-frail patients. Among frail, RARC was only independently associated with shorter LOS (median 8 vs. 9 days, relative ratio [RR] 0.79, p < 0.001). Conversely, among non-frail, RARC was independently associated with lower complications (57.3 vs. 59.1%, odds ratio [OR] 0.82, p = 0.004) and shorter LOS (median 6 vs. 7 days, RR 0.88, p < 0.001), but also predicted higher THCs (+2850.3 US dollars, p = 0.001)., Conclusions: In frail patients, the use of RARC did not result in better short-term outcomes except for one-day advantage in LOS. Conversely, in non-frail patients, the use of RARC resulted in lower complication rates and shorter LOS at the cost of higher THCs. In consequence, the benefit of RARC appears relatively marginal in frail patients and our data do not suggest a clear and clinically-meaningful benefit of RARC over ORC in frail radical cystectomy population., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations., Methods: National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations., Results: There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy., Conclusions: Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cardiac surgeons have a significant history of participating in humanitarian work; however, the outcomes in this arena are not well delineated. We sought to define and describe failure to rescue (FTR) in this setting by analyzing the outcomes of the International Children's Heart Foundation., Methods: From 2008 to 2017, 3009 patients underwent operations during the course of an International Children's Heart Foundation mission. Of these, 1165 patients had at least one complication. These patients were divided into those who ultimately died (FTR group, n = 107) and those who survived (survivor group, n = 1058). Clinical presentation and outcomes were compared., Results: The overall FTR rate was 10%. Patients in the FTR group were significantly younger, weighed less, and were shorter. Children who required a preoperative admission to the intensive care unit were more likely to be in the FTR group. Intraoperative data demonstrated significantly longer cardiopulmonary bypass time among FTR patients, with similar use of intraoperative blood product. Postoperatively, patients in the FTR group had more reintubations than survivors. Cardiopulmonary bypass and intensive care unit times were shown to be significant predictors of FTR. There was a trend between program volume and FTR rate. Program volume appeared to be correlated with FTR., Conclusions: Failure to rescue occurs at a rate of 10% in the humanitarian congenital cardiac surgery setting. The FTR patients were younger, required more intubations, and had significantly more diagnoses of transposition of the great arteries. Longer cardiopulmonary bypass time and intensive care unit admission were associated with increased risk of FTR., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Cardiac complications (CC) after injury are rare but contribute disproportionately to mortality. Variability in rates of CC and failure to rescue (FTR) after CC (FTR-C) within trauma systems may suggest opportunities for improvement, but we have not yet demonstrated the ability to identify high and low performers. We examined center-level rates of CC and FTR-C in a mature trauma system with the hypothesis that high-performing centers for each of these outcomes could be identified., Methods: Using a statewide trauma registry from 2007-2015, we developed multivariable logistic regression models on CC and FTR-C including patient demographics, physiology, comorbidity, and injury data. Predicted probabilities of each outcome were summed to generate expected event rates, which were compared to observed event rates to generate centerlevel observed-to-expected (O:E) ratios. We measured internal consistency between CC and FTR-C for centers using Cronbach's alpha., Results: Cardiac complications occurred in 5,079/278,042 (1.8%; center-level range: 0.9-3.8%) of included patients (median age 55 (IQR 34-76), 84% Caucasian, 60% male, 92% blunt, median ISS 9 (IQR5-16)). Death after CC occurred in 982/5,097 patients for an FTR-C rate of 19.3% (center-level range: 7.8-30.4%). 10/27 centers were high-performers (95% confidence interval for O:E ratio <1) for CC and 2/27 centers were high-performers for FTR-C, but internal consistency between these metrics was poor (alpha = 0.31)., Conclusion: Rates of CC and FTR-C vary significantly between hospitals in mature trauma systems but high-performing centers can be identified. Inconsistent performance between metrics suggests unknown institutional factors underlie performance for CC and FTR., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Complication rates in many complex surgical procedures are associated with the volume of procedures performed., Objectives: To investigate the relationship between hospital volume and complications, mortality, and failure to rescue (FTR) rates in patients undergoing vestibular schwannoma (VS) surgery., Design, Setting, and Participants: The Nationwide Inpatient Sample was used to identify 44,336 patients who underwent VS surgery in 1995-2011. Annual case volumes were stratified by quintiles and defined as very low (≤5 cases/year), low (6-12 cases/year) medium (13-22 cases/year), high (23-37 cases/year), and very high-volume (≥38 cases/year)., Main Outcomes and Measures: Relationships between hospital volume and in-hospital mortality, postoperative complications, as well as FTR rates, defined as death after a major complication, were examined using multivariate regression analysis., Results: Postoperative medical and surgical complications occurred in 5.4% and 14.6% of cases, respectively, and did not differ significantly across volume quintiles. In-hospital mortality decreased with increasing hospital volume, with an incidence of 1.4% for hospitals in the lowest volume quintile compared to 0.1% for hospitals in the top volume quintile. After controlling for all other variables, the odds of in-hospital mortality were lower for medium (OR = 0.19 [0.04-0.93]) and very high-volume hospitals (OR = 0.07 [0.01-0.53]), but not high-volume hospitals (OR = 0.43 [0.05-3.77]). There was no association between hospital volume and the odds of postoperative surgical complications. FTR was associated with hospital volume, with decreasing odds for medium-volume (OR = 0.15 [0.02-0.93]), high-volume (OR = 0.17 [0.04-0.74]), and very high-volume (OR = 0.07 [0.04-0.74]) hospitals., Conclusions: Hospital volume does not appear to be associated with complication rates but is associated with decreased likelihood of FTR after VS surgery., Level of Evidence: NA Laryngoscope, 130:1287-1293, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Data on failure to rescue (FTR) after esophagectomy are sparse. We sought to better understand the patient factors associated with FTR and to assess whether FTR is associated with hospital volume., Methods: We identified all patients undergoing esophagectomy between 2010 and 2014 from the Agency for Healthcare Research and Quality Nationwide Readmission Database. We defined FTR as mortality after a major complication. Multiple logistic regression was used to identify patient factors and hospital-volume associations with FTR., Results: Of 26,820 patients undergoing an esophagectomy, 7130 (26.6%) experienced a major complication. Of those, 1321 did not survive the index hospitalization (FTR rate, 18.5%). Risk factors for FTR included increasing age (adjusted odds ratio [aOR], 1.06; P < .001), congestive heart failure (aOR, 2.07; P < .001), bleeding disorders (aOR, 2.9; P < .001), liver disease (aOR, 2.37; P = .001), and renal failure (aOR, 2.37; P = .002). At the hospital level there was wide variation in FTR rates across hospital volume quintiles, with 21.2% of patients suffering a complication not surviving to discharge at low-volume hospitals compared with 13.4% at high-volume hospitals (P < .001). At low-volume hospitals the highest FTR rates were acute renal failure (35.3%), postoperative hemorrhage (31.9%), and pulmonary failure (28.1%)., Conclusions: One in 5 esophagectomy patients suffering a complication at low-volume hospitals do not survive to discharge. Several patient factors are associated with death after a major complication. Strategies to improve the recognition and management of complications in at-risk patients may be essential to improve outcomes at low-volume hospitals., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery., Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed., Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers., Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.

Background: Pulmonary embolism and deep vein thrombosis are common clinical entities, and the related malpractice suits affect all medical subspecialties. Claims from malpractice litigation were analyzed to understand the demographics of these lawsuits and the common reasons for pursuing litigation., Methods: Cases entered into the Westlaw database from March 5, 1987, to May 31, 2018, were reviewed. Search terms included "pulmonary embolism" and "deep vein thrombosis.", Results: A total of 277 cases were identified. The most frequently identified defendant was an internist (including family practitioner; 33%), followed by an emergency physician (18%), an orthopedic surgeon (16%), and an obstetrician/gynecologist (9%). The most common etiology for pulmonary embolism was prior surgery (41%). The most common allegation was "failure to diagnose and treat" in 62%. Other negligence included the failure to administer prophylactic anticoagulation while in the hospital (18%), failure to prescribe anticoagulation on discharge (8%), failure to administer anticoagulation after diagnosis (8%), and premature discontinuation of anticoagulation (2%). The most frequently claimed injury was death in 222 cases (80%). Verdicts were found for the defendant in 57% of cases and for the plaintiff in 27% and settled in 16%., Conclusions: The most frequently cited negligent act was the failure to give prophylactic anticoagulation, even after discharge. The trends noted in this study may potentially be addressed and therefore prevented by systems-based practice changes. The most common allegation, "failure to diagnose and treat," suggests that first-contact doctors such as emergency physicians and primary care practitioners must maintain a high index of suspicion for deep vein thrombosis/pulmonary embolism., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The clinical response to postoperative complications after lung transplantation (LTx) may contribute to mortality differences among transplantation centers. The ability to avoid mortality after a complication-failure to rescue (FTR)-may be an effective quality metric in LTx., Methods: The United Network for Organ Sharing database was queried for adult, first-time, lung-only transplantations from May 2005 to December 2015. Transplantation centers were stratified into equal-sized terciles on the basis of observed operative mortality rates. Several postoperative complications were identified, including stroke, acute rejection, acute kidney injury requiring hemodialysis, airway dehiscence, and extracorporeal membrane oxygenation 72 hours after surgery. Rates of FTR were calculated as the number of operative mortalities in patients who had complications divided by the number of patients who had any postoperative complications., Results: Our study population included 16,411 LTx operations performed at 69 transplantation centers. LTx centers were stratified into terciles with average perioperative mortality of 4.0% for low-mortality centers, 6.9% for intermediate-mortality centers, and 12.4% for high-mortality centers. Low-mortality centers had slightly lower complication rates (low, 15.0% vs intermediate, 17.1% vs high, 19.1%; P < .001). Differences in FTR rate were significantly more pronounced (low, 14.9% vs intermediate, 23.9% vs high, 34.2%; P < .001). Multivariable logistic regression and generalized linear models demonstrated an independent association between high FTR rates and high mortality in LTx (P < .001)., Conclusions: Differences in rates of FTR contribute significantly to per-center variability in mortality after LTx. FTR can serve as a quality metric to identify opportunities for improvement in management of perioperative adverse events., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)