Variation in postoperative complication rates and opportunities for improvement

Introduction: Complications of hospital care are associated with increased morbidity, mortality, and costs, however, the exact relationship between complications and these outcomes has not been established. The specific aims of this study were to evaluate the variation m postoperative complications and the association between postoperative complications and clinically relevant outcomes (in-hospital mortality, total hospital charges, and hospital length-of-stay [LOS]) in patients having abdominal aortic surgery. Methods: We analyzed hospital discharge data on all patients in 46 non-federal, acute care hospitals in Maryland who had a principal procedure code for abdominal aortic surgery from 1/94-12/96 (N = 2987) for medical and surgical complications and major outcome variables (in-hospital mortality, total hospital charges, and hospital LOS) We adjusted our results for patient age severity of illness, comorbid diseases, hospital volume and surgeon volume. For each complication we calculated the attributable fraction (AF), which is the proportion of deaths that could potentially be eliminated if the complication were presented. Results: The rates of postoperative complications between hospitals varied widely Complications independently associated with increased risk of in-hospital death included cardiac arrest (OR 90. CI 32-251), septicemia (OR 6.1; CI3.3-11.3), acute myocardial infarction (OR 5.7. CI 2.3-14.3), acute renal failure (OR 5.0; CI 2.3-11.0). surgical complications after,) procedure (OR 3.1; CI 2.0-4.9), reoperation for bleeding (OR 2.2; 1.1-4.8) and reintubation (OR 1.0; CI 1.3-2.8). The independent increase in hospital charges for complications were sepsis - $33.000, infected vascular graft - $33.000, postoperative infection - $28.000, acute renal failure - $18,000, pneumonia - $16,000, and reintubation - $10,000. The atributable fraction ranged from 47% for cardiac arrest to 3% for reoperation for bleeding. If the outlier hospital (defined as the hospital that performed at least 50 cases with the highest complication rate) achieved the 25 perceutile rate of complications, they would save reintubation - $296.000. acute renal failure - $157,000, infected vascular graft - $134.000, an sepsis - $124.000. Conclusions: Postoperative complication rates vary widely and are independently associated with increased risk of in-hospital mortality and excess costs. These data suggests that significant reductions in in-hospital mortality and costs can be achieved by reducing the rate of postoperative complications, and that hospitals should focus efforts on reducing those complications that have a high attributable fraction.