Frailty, hospital volume, and failure to rescue after head and neck cancer surgery

Objectives/Hypothesis: We previously reported that high-volume hospital head and neck cancer (HNCA) surgical care is associated with decreased mortality, largely explained by reduced rates of failure to rescue. Frailty is an independent predictor of mortality, but is significantly less likely in patients receiving high-volume care. We investigate whether differences in frailty rates explain the relationship between volume and outcomes in HNCA patients and whether frailty confounds the relationship between failure to rescue and mortality. Study Design: Cross-sectional analysis. Methods: Discharge data from the Nationwide Inpatient Sample for 159,301 patients who underwent ablative surgery for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 to 2010 were analyzed using cross-tabulations and multivariate regression. Failure to rescue was defined as death after a major complication. Frailty was defined using frailty-defining diagnosis clusters from the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Results: High-volume hospital care was associated with a lower odds of frailty (odds ratio [OR]: 0.7 [95% confidence interval [CI]: 0.5-1.0]). Frail patients had higher odds of postoperative complications (OR: 4.1 [95% CI: 3.4-4.9]) and mortality (OR: 2.0 [95% CI: 1.3-3.2]), but no difference in failure to rescue rates (OR: 1.0 [95% CI: 0.6-1.6]). High-volume care was not associated with differences in odds of complications (OR: 1.0 [95% CI: 0.8-1.2]), but was associated with significantly decreased odds of mortality (OR: 0.6 [95% CI: 0.5-0.9]) and failure to rescue (OR: 0. 6 [95% CI: 0.3-1.0]), which was not attenuated by adjusting for frailty. Conclusions: High-volume HNCA surgical care is associated with a significantly lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in frailty or complication rates.