Research Original Investigation
Volume-Outcome Effect in Cardiovascular Surgery
Invited Commentary
Rescuing Failures Can Large Data Sets Provide the Answer? Lillian S. Kao, MD, MS
Secondary analyses of large data sets including that by Gonzalez et al1 have repeatedly reported on an association between failure to rescue after surgery, or death after a major complication, and outcome.2-4 While few provide insight as to how to change this relationship, these analyses can genRelated article page 119 erate hypotheses about why high-mortality hospitals have higher rates of failure to rescue. For example, studies have identified higher rates with lower levels of intensive care unit facilities,5 poor nurse practice environments,6 and less aggressive treatment style.7 However, these data sets are not granular enough to determine whether these are actual causes of failure to rescue or just surrogates for other factors such as better teamwork and communication, which Gonzalez and colleagues have suggested as a potential solution. Identifying the correct targets for improvement is essential as interventions are likely to be multifaceted, resource intensive, and costly.
ARTICLE INFORMATION Author Affiliation: Department of Surgery, University of Texas Health Science Center at Houston, Houston. Corresponding Author: Lillian S. Kao, MD, MS, Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Ste 30S 62008, Houston, TX 77026 ([email protected]). Published Online: December 11, 2013. doi:10.1001/jamasurg.2013.3674. Conflict of Interest Disclosures: None reported. REFERENCES 1. Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Understanding the volume-outcome effect in
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Researchers need to move beyond documenting associations to performing hospital- and patient-level studies to understand where and why failures to rescue occur and how they can be prevented. Delay in diagnosing and treating complications may be related to processes, structure, or both. Thus, should interventions be directed at improving specific processes involved in postoperative care or at enhancing infrastructure and resources? If a combination of interventions is required, which ones should be instituted first or deserve the most attention? Furthermore, how does context influence the effectiveness of interventions to reduce failure to rescue? Interventions that work in one setting may not be successful in others. Should improvement efforts instead focus on changing the safety culture? Until these questions can be answered, associations between failure to rescue and mortality will continue to exist and hospitals will continue to fail with patients ultimately suffering the consequences.
cardiovascular surgery: the role of failure to rescue [published online December 11, 2013]. JAMA Surg. doi:10.1001/jamasurg.2013.3649. 2. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-1375. 3. Henneman D, Snijders HS, Fiocco M, et al. Hospital variation in failure to rescue after colorectal cancer surgery: results of the Dutch Surgical Colorectal Audit. Ann Surg Oncol. 2013;20(7):2117-2123. 4. Reddy HG, Shih T, Englesbe MJ, et al. Analyzing “failure to rescue”: is this an opportunity for outcome improvement in cardiac surgery? Ann Thorac Surg. 2013;95(6):1976-1981.
5. Henneman D, van Leersum NJ, Ten Berge M, et al. Failure-to-rescue after colorectal cancer surgery and the association with three structural hospital factors. Ann Surg Oncol. 2013;20(11):33703376. 6. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43(4):1145-1163. 7. Silber JH, Kaestner R, Even-Shoshan O, Wang Y, Bressler LJ. Aggressive treatment style and surgical outcomes. Health Serv Res. 2010;45(6, pt 2):1872-1892.
JAMA Surgery February 2014 Volume 149, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/05/2015
jamasurgery.com
Volume-Outcome Effect in Cardiovascular Surgery
Invited Commentary
Rescuing Failures Can Large Data Sets Provide the Answer? Lillian S. Kao, MD, MS
Secondary analyses of large data sets including that by Gonzalez et al1 have repeatedly reported on an association between failure to rescue after surgery, or death after a major complication, and outcome.2-4 While few provide insight as to how to change this relationship, these analyses can genRelated article page 119 erate hypotheses about why high-mortality hospitals have higher rates of failure to rescue. For example, studies have identified higher rates with lower levels of intensive care unit facilities,5 poor nurse practice environments,6 and less aggressive treatment style.7 However, these data sets are not granular enough to determine whether these are actual causes of failure to rescue or just surrogates for other factors such as better teamwork and communication, which Gonzalez and colleagues have suggested as a potential solution. Identifying the correct targets for improvement is essential as interventions are likely to be multifaceted, resource intensive, and costly.
ARTICLE INFORMATION Author Affiliation: Department of Surgery, University of Texas Health Science Center at Houston, Houston. Corresponding Author: Lillian S. Kao, MD, MS, Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Ste 30S 62008, Houston, TX 77026 ([email protected]). Published Online: December 11, 2013. doi:10.1001/jamasurg.2013.3674. Conflict of Interest Disclosures: None reported. REFERENCES 1. Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Understanding the volume-outcome effect in
124
Researchers need to move beyond documenting associations to performing hospital- and patient-level studies to understand where and why failures to rescue occur and how they can be prevented. Delay in diagnosing and treating complications may be related to processes, structure, or both. Thus, should interventions be directed at improving specific processes involved in postoperative care or at enhancing infrastructure and resources? If a combination of interventions is required, which ones should be instituted first or deserve the most attention? Furthermore, how does context influence the effectiveness of interventions to reduce failure to rescue? Interventions that work in one setting may not be successful in others. Should improvement efforts instead focus on changing the safety culture? Until these questions can be answered, associations between failure to rescue and mortality will continue to exist and hospitals will continue to fail with patients ultimately suffering the consequences.
cardiovascular surgery: the role of failure to rescue [published online December 11, 2013]. JAMA Surg. doi:10.1001/jamasurg.2013.3649. 2. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-1375. 3. Henneman D, Snijders HS, Fiocco M, et al. Hospital variation in failure to rescue after colorectal cancer surgery: results of the Dutch Surgical Colorectal Audit. Ann Surg Oncol. 2013;20(7):2117-2123. 4. Reddy HG, Shih T, Englesbe MJ, et al. Analyzing “failure to rescue”: is this an opportunity for outcome improvement in cardiac surgery? Ann Thorac Surg. 2013;95(6):1976-1981.
5. Henneman D, van Leersum NJ, Ten Berge M, et al. Failure-to-rescue after colorectal cancer surgery and the association with three structural hospital factors. Ann Surg Oncol. 2013;20(11):33703376. 6. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43(4):1145-1163. 7. Silber JH, Kaestner R, Even-Shoshan O, Wang Y, Bressler LJ. Aggressive treatment style and surgical outcomes. Health Serv Res. 2010;45(6, pt 2):1872-1892.
JAMA Surgery February 2014 Volume 149, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/05/2015
jamasurgery.com
