Failure to Rescue, An Additional Quality Marker Next to Complication and Death Rate, in Abdominal Aortic Aneurysm Surgery

Introduction - The aim was to explore the composite measure ‘Failure To Rescue’ (FTR) for the comparison of quality of care of abdominal aortic aneurysm (AAA) surgery between hospitals. FTR is defined as the relationship between mortality and patients with adverse events. Also, the relation of FTR with hospital volume and the amount and rate of major complications were evaluated. Methods - Patients prospectively collected in 2013-2015 in the Dutch Surgical Aneurysm Audit (DSAA) were analysed. FTR (mortality/major complications) was calculated for all AAA surgery, as well as for the subgroups elective AAA (EAAA) and acute AAA (AAAA) surgery. Major complications were defined as events resulting in reinterventions, prolonged hospital stay and/or death. Predictors of FTR were analysed with uni- and multivariate analysis. Analysis was performed on patient level. Hospital volume was split into tertiles and each group was compared for unadjusted and adjusted mortality and major complications, as well as FTR. Funnel plots were constructed for hospital comparisons. Results - A total of 9258 patients were analysed in 61 hospitals. There were 7149 EAAA patients (77.2%) and 2109 AAAA patients (22.8%): 641 acute symptomatic (SAAA) (6.9%) and 1468 ruptured (RAAA) patients (15.9%). There were 2785 (30.1%) patients with complications of which 2161 (77.6%) had at least one major complication with a mean FTR of 28.4% (n=613) (range 0-60%): EAAA surgery 11.6% and AAAA surgery 47.7%. Glasgow Coma Scale, age, pulse rate, creatinin, ECG and operative setting (urgency) were independently associated with FTR. Four hospitals had significant better FTR than the national mean of which two with a relatively high percentage of major complications. No hospitals performing significantly less than the national mean FTR could be identified. The adjusted FTR overall was not statistically significant associated with hospital volume. However, for the subgroup of AAAA patients volume was significantly associated with the adjusted percentage of major complications and mortality (OR 0.62 (95%CI 0.49-0.78) and 0.64 (95%CI 0.48-0.87). Conclusion - There was a wide variation of FTR between hospitals. Hospitals could be identified with both significant low mortality rates and FTR compared to indifferent percentages of major complications, indicating that they perform better than the national average regarding preventable death. There is no association between hospital volume and FTR. High volume AAAA hospitals have significant lower complication and death rate, however not resulting in better FTR. FTR is a useful additional quality marker, next to complication and death rate, in order to identify hospitals performing better or worse than the national average.