What does this research mean for the field?

Hospital rankings for postoperative pulmonary complications correlate weakly with mortality overall but more strongly in specific high-risk surgeries, and combining pulmonary complication rates with mortality rates significantly enhances the detection of hospital quality outliers. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

August 1, 2003

Postoperative Mortality and Pulmonary Complication Rankings

Structured PICO

Does supplementing mortality rankings with pulmonary complication rates improve hospital outlier detection in noncardiac surgery?

Population

103,176 noncardiac surgery patients from 123 VA hospitals enrolled between 1/1/94 and 8/31/95. Excluded: preoperative pneumonia, ventilator dependent, comatose, or do-not-resuscitate patients.

Intervention

Hospital rankings including pulmonary complication rates (respiratory failure, pneumonia)

Comparator

Hospital rankings using mortality rates alone

Outcome

Correlation between hospital rankings of postoperative respiratory failure, pneumonia, and mortality rates

Supplementing mortality rankings with pulmonary complication rates enhances hospital outlier detection for quality assessment in noncardiac surgery.

Abstract

BACKGROUND: Postoperative mortality rankings are used alone for quality assessment. OBJECTIVES: To determine the correlation between hospital rankings of postoperative respiratory failure, pneumonia, and mortality rates and to assess the influence of hospital volume, type of surgery, and time on these correlations. To compare hospital outlier detection with and without pulmonary complication rates. RESEARCH DESIGN: Prospective observational study. SUBJECTS: 103,176 noncardiac surgery patients from 123 VA hospitals enrolled between 1/1/94 and 8/31/95. Preoperative pneumonia, ventilator dependent, comatose, or do-not-resuscitate patients were excluded. MEASURES: Respiratory failure was defined as greater than 48 hours of ventilator assistance or postoperative reintubation. Pneumonia was defined as positive sputum cultures with antibiotic treatment or chest x-ray infiltrate diagnosed as pneumonia or pneumonitis. Mortality was defined as death within 30 days of surgery. Hospital rankings were assigned using risk-adjusted observed-to-expected ratios. RESULTS: There was significant, but weak correlation between mortality and pulmonary complication rankings (r = 0.21, P = 0.02 for pneumonia; r = 0.22, P = 0.01 for respiratory failure). Correlations with mortality rankings were highest for thoracic (r = 0.42, P < 0.001 for pneumonia; r = 0.38, P < 0.001 for respiratory failure) and vascular surgery (r = 0.26, P = 0.02 for pneumonia; r = 0.35, P < 0.001 for respiratory failure). Supplementing mortality with pulmonary complication outlier designations enhanced outlier detection for 47% of hospitals overall, and for 29% in the lowest caseload quartile. CONCLUSIONS: Pulmonary complication rankings correlate weakly with mortality overall, but have higher correlations in thoracic, vascular, and upper abdominal surgery. Examining pneumonia and respiratory failure outlier status with mortality outlier status enhances hospital outlier detection even in low-volume hospitals.

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