Hospital-level variation in secondary complications after surgery

Elliot Wakeam, Joseph A. Hyder, Stuart R. Lipsitz, Mark E. Cohen, Dennis P. Orgill, Michael J. Zinner, Cliff Y. Ko, Bruce L. Hall, Samuel R.G. Finlayson

Research output: Contribution to journalArticlepeer-review

33 Scopus citations


To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality. Background: Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or "index" complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails. Methods: We used American College of Surgeons' National Surgical Quality Improvement Program data (2008-2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk-and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality. Results: A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95-5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41-9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48-9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31-2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20-9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6-2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80-3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26-6.81). Conclusions: Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.

Original languageEnglish
Pages (from-to)493-501
Number of pages9
JournalAnnals of surgery
Issue number3
StatePublished - Jan 1 2016


  • Benchmarking
  • failure to rescue
  • performance measurement
  • surgery


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