0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation | Association of VA Surgeons

Thirty-Day Postoperative Mortality Risk Estimates and 1-Year Survival in Veterans Health Administration Surgery Patients

Tracy Smith, MS1; Xinli Li, PhD1; William Nylander, MD, MBA1; William Gunnar, MD, JD2,3
[+] Author Affiliations
1Veterans Health Administration, National Surgery Office, Glendale, Colorado
2Veterans Health Administration, National Surgery Office, Washington DC
3Department of Surgery, The George Washington University, Washington DC
JAMA Surg. 2016;151(5):417-422. doi:10.1001/jamasurg.2015.4882.
Text Size: A A A
Published online

Importance  For more than 2 decades, the Veterans Health Administration (VHA) has relied on risk-adjusted, postoperative, 30-day mortality data as a measure of surgical quality of care. Recently, the use of 30-day mortality data has been criticized based on a theory that health care professionals manage patient care to meet the metric and that other outcome metrics are available.

Objectives  To determine whether postoperative mortality data identify a delay in care to meet a 30-day mortality metric and to evaluate whether 30-day mortality risk score groups stratify survival patterns up to 365 days after surgery in surgical procedures assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP).

Design, Setting, and Participants  Patients undergoing VASQIP-assessed surgical procedures within the VHA from October 1, 2011, to September 30, 2013, were evaluated. Data on 365-day survival follow-up of 212 733 surgical cases using VHA Vital Status and admission records were obtained with 10 947 mortality events. Data analysis was conducted from September 3, 2014, to November 9, 2015.

Main Outcomes and Measures  Survival up to 365 days after surgery for the overall cohort divided into 10 equal groups (deciles).

Results  There were 10 947 mortality events identified in a cohort of 212 733 surgical patients. The mean probability of death was 1.03% (95% CI, 1.01%-1.04%). Risk estimate groups in the 212 733 surgical cases analyzed showed significantly different postoperative survival, with consistency beyond the time frame for which they were developed. The lowest risk decile had the highest 365-day survival probability (99.74%; 95% CI, 99.66%-99.80%); the highest risk decile had the lowest 365-day survival probability (72.04%; 95% CI, 71.43%-72.64%). The 9 lowest risk deciles had linear survival curves from 0 to 365 postoperative days, with the highest risk decile having early survival risk and becoming more linear after the first 180 days. Survival curves between 25 and 35 days were consistent for all risk deciles and showed no evidence that mortality rates were affected in the immediate period beyond day 30. The setting of mortality varied by postoperative day ranges, with index hospitalization events declining and deaths outside of the hospital increasing up to 365 days.

Conclusions and Relevance  Deciles of 30-day mortality estimates are associated with significantly different survival outcomes at 365 days even after removing patients who died within the first 30 postoperative days. No evidence of delays in patient care and treatment to meet a 30-day metric were identified. These findings reinforce the usefulness of 30-day mortality risk stratification as a surrogate for long-term outcomes.

Figures in this Article

Figures

Place holder to copy figure label and caption
Figure 1.
Overall Survival Curves for Risk Deciles

Overall Veterans Affairs Surgical Quality Improvement Program population.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Survival Curves for Risk Deciles, Excluding Patient Mortalities Prior to Postoperative Day 30

Overall Veterans Affairs Surgical Quality Improvement Program population.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Survival Curves for Risk Deciles, Postoperative Days 25-35

Overall Veterans Affairs Surgical Quality Improvement Program population.

Graphic Jump Location

Tables

References

Correspondence

CME


You need to register in order to view this quiz.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,548 Views
2 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
brightcove.createExperiences();