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Original Investigation |

Failure to Rescue in Safety-Net Hospitals:  Availability of Hospital Resources and Differences in Performance

Elliot Wakeam, MD1,2; Nathanael D. Hevelone, MPH1; Rebecca Maine, MD1; Jabaris Swain, MD1; Stuart A. Lipsitz, ScD1; Samuel R. G. Finlayson, MD, MPH1; Stanley W. Ashley, MD1; Joel S. Weissman, PhD1,3
[+] Author Affiliations
1Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
2Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
3Patient-Centered Comparative Effectiveness Research Center, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Surg. 2014;149(3):229-235. doi:10.1001/jamasurg.2013.3566.
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Importance  Failure to rescue (FTR), the mortality rate among surgical patients with complications, is an emerging quality indicator. Hospitals with a high safety-net burden, defined as the proportion of patients covered by Medicaid or uninsured, provide a disproportionate share of medical care to vulnerable populations. Given the financial strains on hospitals with a high safety-net burden, availability of clinical resources may have a role in outcome disparities.

Objectives  To assess the association between safety-net burden and FTR and to evaluate the effect of clinical resources on this relationship.

Design, Setting, and Participants  A retrospective cohort of 46 519 patients who underwent high-risk inpatient surgery between January 1, 2007, and December 31, 2010, was assembled using the Nationwide Inpatient Sample. Hospitals were divided into the following 3 safety-net categories: high-burden hospitals (HBHs), moderate-burden hospitals (MBHs), and low-burden hospitals (LBHs). Bivariate and multivariate analyses controlling for patient, procedural, and hospital characteristics, as well as clinical resources, were used to evaluate the relationship between safety-net burden and FTR.

Main Outcomes and Measures  FTR.

Results  Patients in HBHs were younger (mean age, 65.2 vs 68.2 years; P = .001), more likely to be of black race (11.3% vs 4.2%, P < .001), and less likely to undergo an elective procedure (39.3% vs 48.6%, P = .002) compared with patients in LBHs. The HBHs were more likely to be large, major teaching facilities and to have high levels of technology (8.6% vs 4.0%, P = .02), sophisticated internal medicine (7.7% vs 4.3%, P = .10), and high ratios of respiratory therapists to beds (39.7% vs 21.1%, P < .001). However, HBHs had lower proportions of registered nurses (27.9% vs 38.8%, P = .02) and were less likely to have a positron emission tomographic scanner (15.4% vs 22.0%, P = .03) and a fully implemented electronic medical record (12.6% vs 17.8%, P = .03). Multivariate analyses showed that HBHs (adjusted odds ratio, 1.35; 95% CI, 1.19-1.53; P < .001) and MBHs (adjusted odds ratio, 1.15; 95% CI, 1.05-1.27; P = .005) were associated with higher odds of FTR compared with LBHs, even after adjustment for clinical resources.

Conclusions and Relevance  Despite access to resources that can improve patient rescue rates, HBHs had higher odds of FTR, suggesting that availability of hospital clinical resources alone does not explain increased FTR rates.

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Figure 1.
Derivation of the Failure to Rescue (FTR) Study Population

AAA indicates abdominal aortic aneurysm; AHA, American Hospital Association; and NIS, Nationwide Inpatient Sample. aMajor complications defined as deep vein/pulmonary embolism, surgical site infection, acute renal failure, pneumonia, respiratory failure, acute myocardial infarction/cardiac event, shock/hypotension/sepsis, and other infection.

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Figure 2.
Adjusted Rates of Failure to Rescue (FTR) by Safety Net Burden, Stratified by Procedure

AAA indicates abdominal aortic aneurysm; HBHs, high-burden hospitals; LBHs, low-burden hospitals; and MBHs, moderate-burden hospitals.

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