Variation in hospital mortality rates with inpatient cancer surgery.

OBJECTIVE: To elucidate clinical mechanisms underlying variation in hospital mortality after cancer surgery BACKGROUND: : Thousands of Americans die every year undergoing elective cancer surgery. Wide variation in hospital mortality rates suggest opportunities for improvement, but these efforts are limited by uncertainty about why some hospitals have poorer outcomes than others. METHODS: Using data from the 2006-2007 National Cancer Data Base, we ranked 1279 hospitals according to a composite measure of perioperative mortality after operations for bladder, esophagus, colon, lung, pancreas, and stomach cancers. We then conducted detailed medical record review of 5632 patients at 1 of 19 hospitals with low mortality rates (2.1%) or 30 hospitals with high mortality rates (9.1%). Hierarchical logistic regression analyses were used to compare risk-adjusted complication incidence and case-fatality rates among patients experiencing serious complications. RESULTS: The 7.0% absolute mortality difference between the 2 hospital groups could be attributed to higher mortality from surgical site, pulmonary, thromboembolic, and other complications. The overall incidence of complications was not different between hospital groups [21.2% vs 17.8%; adjusted odds ratio (OR) = 1.34, 95% confidence interval (CI): 0.93-1.94]. In contrast, case-fatality after complications was more than threefold higher at high mortality hospitals than at low mortality hospitals (25.9% vs 13.6%; adjusted OR = 3.23, 95% CI: 1.56-6.69). CONCLUSIONS: Low mortality and high mortality hospitals are distinguished less by their complication rates than by how frequently patients die after a complication. Strategies for ensuring the timely recognition and effective management of postoperative complications will be essential in reducing mortality after cancer surgery.

Safety culture and complications after bariatric surgery.

OBJECTIVE: To assess relationships between safety culture and complications within 30 days of bariatric surgery. BACKGROUND: Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically. METHODS: We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume. RESULTS: All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied. CONCLUSIONS: Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.