Failure to Rescue - a Closer Look at Mortality Rates Has No Added Value for Hospital Comparisons but Is Useful for Team Quality Assessment in Abdominal Aortic Aneurysm Surgery in The Netherlands

Niki Lijftogt; Eleonora G Karthaus; Anco Vahl; Erik W van Zwet; Esmee M van der Willik; Robertus A E M Tollenaar; Jaap F Hamming; Michel W J M Wouters; Dutch Society of Vascular Surgery; Steering Committee of the Dutch Surgical Aneurysm Audit; Dutch Institute for Clinical Auditing

doi:10.1016/j.ejvs.2018.06.062

Failure to Rescue - a Closer Look at Mortality Rates Has No Added Value for Hospital Comparisons but Is Useful for Team Quality Assessment in Abdominal Aortic Aneurysm Surgery in The Netherlands

Eur J Vasc Endovasc Surg. 2018 Nov;56(5):652-661. doi: 10.1016/j.ejvs.2018.06.062. Epub 2018 Aug 23.

Authors

Niki Lijftogt¹, Eleonora G Karthaus², Anco Vahl³, Erik W van Zwet⁴, Esmee M van der Willik⁵, Robertus A E M Tollenaar⁶, Jaap F Hamming⁷, Michel W J M Wouters⁸; Dutch Society of Vascular Surgery; Steering Committee of the Dutch Surgical Aneurysm Audit; Dutch Institute for Clinical Auditing

Collaborators

L H Van den Akker, P J Van den Akker, G J Akkersdijk, G P Akkersdijk, W L Akkersdijk, M G van Andringa de Kempenaer, C H Arts, J A Avontuur, J G Baal, O J Bakker, R Balm, W B Barendregt, M H Bender, B L Bendermacher, M van den Berg, P Berger, R J Beuk, J D Blankensteijn, R J Bleker, J H Bockel, M E Bodegom, K E Bogt, A P Boll, M H Booster, B L Borger van der Burg, G J de Borst, W T Bos-van Rossum, J Bosma, J M Botman, L H Bouwman, J C Breek, V Brehm, M J Brinckman, T H van den Broek, H L Brom, M T de Bruijn, J L de Bruin, P Brummel, J P van Brussel, S E Buijk, M G Buimer, D H Burger, H C Buscher, G den Butter, E Cancrinus, P H Castenmiller, G Cazander, H M Coveliers, P H Cuypers, J H Daemen, I Dawson, A F Derom, A R Dijkema, J Diks, M K Dinkelman, M Dirven, D E Dolmans, R C van Doorn, L M van Dortmont, M M van der Eb, D Eefting, G J van Eijck, J W Elshof, B H Elsman, A van der Elst, M I van Engeland, R G van Eps, M J Faber, W M de Fijter, B Fioole, W M Fritschy, R H Geelkerken, W B van Gent, G J Glade, B Govaert, R P Groenendijk, H G de Groot, R F van den Haak, E F de Haan, G F Hajer, J F Hamming, E S van Hattum, C E Hazenberg, P P Hedeman Joosten, J N Helleman, L G van der Hem, J M Hendriks, J A van Herwaarden, J M Heyligers, J W Hinnen, R J Hissink, G H Ho, P T den Hoed, M T Hoedt, F van Hoek, R Hoencamp, W H Hoffmann, A W Hoksbergen, E J Hollander, L C Huisman, R G Hulsebos, K M Huntjens, M M Idu, M J Jacobs, M F van der Jagt, J R Jansbeken, R J Janssen, H H Jiang, S C de Jong, V Jongkind, M R Kapma, B P Keller, A Khodadade Jahrome, J K Kievit, P L Klemm, P Klinkert, B Knippenberg, N A Koedam, M J Koelemaij, J L Kolkert, G G Koning, O H Koning, A G Krasznai, R M Krol, R H Kropman, R R Kruse, L van der Laan, M J van der Laan, J H van Laanen, J H Lardenoye, J A Lawson, D A Legemate, V J Leijdekkers, M S Lemson, M M Lensvelt, M A Lijkwan, R C Lind, F T van der Linden, P F Liqui Lung, M J Loos, M C Loubert, D E Mahmoud, C G Manshanden, E C Mattens, R Meerwaldt, B M Mees, R Metz, R C Minnee, J C de Mol van Otterloo, F L Moll, Y C Montauban van Swijndregt, M J Morak, R H van de Mortel, W Mulder, S K Nagesser, C C Naves, J H Nederhoed, A M Nevenzel-Putters, A J de Nie, D H Nieuwenhuis, J Nieuwenhuizen, R C van Nieuwenhuizen, D Nio, A P Oomen, B I Oranen, J Oskam, H W Palamba, A G Peppelenbosch, A S van Petersen, T F Peterson, B J Petri, M E Pierie, A J Ploeg, R A Pol, E D Ponfoort, P P Poyck, A Prent, S Ten Raa, J T Raymakers, M Reichart, B L Reichmann, M M Reijnen, A Rijbroek, M J van Rijn, R A de Roo, E V Rouwet, C G Rupert, B R Saleem, M R van Sambeek, M G Samyn, H P van 't Sant, J van Schaik, P M van Schaik, D M Scharn, M R Scheltinga, A Schepers, P M Schlejen, F J Schlosser, F P Schol, O Schouten, M H Schreinemacher, M A Schreve, G W Schurink, C J Sikkink, M P Siroen, A Te Slaa, H J Smeets, L Smeets, A A de Smet, P de Smit, P C Smit, T M Smits, M G Snoeijs, A O Sondakh, T J van der Steenhoven, S M van Sterkenburg, D A Stigter, H Stigter, R P Strating, G N Stultiëns, J E Sybrandy, J A Teijink, B J Telgenkamp, M J Testroote, R M The, W J Thijsse, I F Tielliu, R B van Tongeren, R J Toorop, J H Tordoir, E Tournoij, M Truijers, K Türkcan, R P Tutein Nolthenius, Ç Ünlü, A A Vafi, A C Vahl, E J Veen, H T Veger, M G Veldman, H J Verhagen, B A Verhoeven, C F Vermeulen, E G Vermeulen, B P Vierhout, M J Visser, J A van der Vliet, C J Vlijmen-van Keulen, H G Voesten, R Voorhoeve, A W Vos, B de Vos, G A Vos, B H Vriens, P W Vriens, A C de Vries, J P de Vries, M de Vries, C van der Waal, E J Waasdorp, B M Wallis de Vries, L A van Walraven, J L van Wanroij, M C Warlé, V van Weel, A M van Well, G M Welten, R J Welten, J J Wever, A M Wiersema, O R Wikkeling, W I Willaert, J Wille, M C Willems, E M Willigendael, W Wisselink, M E Witte, C H Wittens, I C Wolf-de Jonge, O Yazar, C J Zeebregts, M L van Zeeland, L H Van den Akker, P J Van den Akker, G J Akkersdijk, G P Akkersdijk, W L Akkersdijk, M G van Andringa de Kempenaer, C H Arts, J A Avontuur, J G Baal, O J Bakker, R Balm, W B Barendregt, M H Bender, B L Bendermacher, M van den Berg, P Berger, R J Beuk, J D Blankensteijn, R J Bleker, J H Bockel, M E Bodegom, K E Bogt, A P Boll, M H Booster, B L Borger van der Burg, G J de Borst, W T Bos-van Rossum, J Bosma, J M Botman, L H Bouwman, J C Breek, V Brehm, M J Brinckman, T H van den Broek, H L Brom, M T de Bruijn, J L de Bruin, P Brummel, J P van Brussel, S E Buijk, M G Buimer, D H Burger, H C Buscher, G den Butter, E Cancrinus, P H Castenmiller, G Cazander, H M Coveliers, P H Cuypers, J H Daemen, I Dawson, A F Derom, A R Dijkema, J Diks, M K Dinkelman, M Dirven, D E Dolmans, R C van Doorn, L M van Dortmont, M M van der Eb, D Eefting, G J van Eijck, J W Elshof, B H Elsman, A van der Elst, M I van Engeland, R G van Eps, M J Faber, W M de Fijter, B Fioole, W M Fritschy, R H Geelkerken, W B van Gent, G J Glade, B Govaert, R P Groenendijk, H G de Groot, R F van den Haak, E F de Haan, G F Hajer, J F Hamming, E S van Hattum, C E Hazenberg, P P Hedeman Joosten, J N Helleman, L G van der Hem, J M Hendriks, J A van Herwaarden, J M Heyligers, J W Hinnen, R J Hissink, G H Ho, P T den Hoed, M T Hoedt, F van Hoek, R Hoencamp, W H Hoffmann, A W Hoksbergen, E J Hollander, L C Huisman, R G Hulsebos, K M Huntjens, M M Idu, M J Jacobs, M F van der Jagt, J R Jansbeken, R J Janssen, H H Jiang, S C de Jong, V Jongkind, M R Kapma, B P Keller, A Khodadade Jahrome, J K Kievit, P L Klemm, P Klinkert, B Knippenberg, N A Koedam, M J Koelemaij, J L Kolkert, G G Koning, O H Koning, A G Krasznai, R M Krol, R H Kropman, R R Kruse, L van der Laan, M J van der Laan, J H van Laanen, J H Lardenoye, J A Lawson, D A Legemate, V J Leijdekkers, M S Lemson, M M Lensvelt, M A Lijkwan, R C Lind, F T van der Linden, P F Liqui Lung, M J Loos, M C Loubert, D E Mahmoud, C G Manshanden, E C Mattens, R Meerwaldt, B M Mees, R Metz, R C Minnee, J C de Mol van Otterloo, F L Moll, Y C Montauban van Swijndregt, M J Morak, R H van de Mortel, W Mulder, S K Nagesser, C C Naves, J H Nederhoed, A M Nevenzel-Putters, A J de Nie, D H Nieuwenhuis, J Nieuwenhuizen, R C van Nieuwenhuizen, D Nio, A P Oomen, B I Oranen, J Oskam, H W Palamba, A G Peppelenbosch, A S van Petersen, T F Peterson, B J Petri, M E Pierie, A J Ploeg, R A Pol, E D Ponfoort, P P Poyck, A Prent, S Ten Raa, J T Raymakers, M Reichart, B L Reichmann, M M Reijnen, A Rijbroek, M J van Rijn, R A de Roo, E V Rouwet, C G Rupert, B R Saleem, M R van Sambeek, M G Samyn, H P van 't Sant, J van Schaik, P M van Schaik, D M Scharn, M R Scheltinga, A Schepers, P M Schlejen, F J Schlosser, F P Schol, O Schouten, M H Schreinemacher, M A Schreve, G W Schurink, C J Sikkink, M P Siroen, A Te Slaa, H J Smeets, L Smeets, A A de Smet, P de Smit, P C Smit, T M Smits, M G Snoeijs, A O Sondakh, T J van der Steenhoven, S M van Sterkenburg, D A Stigter, H Stigter, R P Strating, G N Stultiëns, J E Sybrandy, J A Teijink, B J Telgenkamp, M J Testroote, R M The, W J Thijsse, I F Tielliu, R B van Tongeren, R J Toorop, J H Tordoir, E Tournoij, M Truijers, K Türkcan, R P Tutein Nolthenius, Ç Ünlü, A A Vafi, A C Vahl, E J Veen, H T Veger, M G Veldman, H J Verhagen, B A Verhoeven, C F Vermeulen, E G Vermeulen, B P Vierhout, M J Visser, J A van der Vliet, C J Vlijmen-van Keulen, H G Voesten, R Voorhoeve, A W Vos, B de Vos, G A Vos, B H Vriens, P W Vriens, A C de Vries, J P de Vries, M de Vries, C van der Waal, E J Waasdorp, B M Wallis de Vries, L A van Walraven, J L van Wanroij, M C Warlé, V van Weel, A M van Well, G M Welten, R J Welten, J J Wever, A M Wiersema, O R Wikkeling, W I Willaert, J Wille, M C Willems, E M Willigendael, W Wisselink, M E Witte, C H Wittens, I C Wolf-de Jonge, O Yazar, C J Zeebregts, M L van Zeeland

Affiliations

¹ Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands. Electronic address: n.lijftogt@gmail.com.
² Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
³ Department of Surgery and Clinical Epidemiology, OLVG, Amsterdam, The Netherlands.
⁴ Department of Medical Statistics, Leiden University, Leiden, The Netherlands.
⁵ Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
⁶ Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
⁷ Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
⁸ Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Surgery, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.

PMID: 30145163
DOI: 10.1016/j.ejvs.2018.06.062

Abstract

Objectives: Failure to rescue (FTR) is a composite quality indicator, defined as the proportion of deceased patients following major complications. The aims of this study were to compare FTR with mortality for hospital comparisons in abdominal aortic aneurysm (AAA) surgery in The Netherlands and investigate hospital volume and associated factors.

Methods: Patients prospectively registered between 2013 and 2015 in the Dutch Surgical Aneurysm Audit (DSAA) were analysed. FTR was analysed for AAA patients and subgroups elective (EAAA) and acute (AAAA; symptomatic or ruptured) aneurysms. Variables and hospital volume were analysed by uni- and multivariable regression analysis. Adjusted hospital comparisons for mortality, major complications, and FTR were presented in funnel plots. Isomortality lines were constructed when presenting FTR and major complication rates.

Results: A total of 9258 patients were analysed in 61 hospitals: 7149 EAAA patients (77.2%) and 2109 AAAA patients (22.8%). There were 2785 (30.1%) patients with complications (unadjusted range 5-65% per hospital): 2161 (77.6%) with major and 624 (28.4%) patients with minor complications. Overall mortality was 6.6% (adjusted range 0-16% per hospital) and FTR was 28.4% (n = 613) (adjusted range 0-60% per hospital). Glasgow Coma Scale, age, pulse, creatinine, electrocardiography, and operative setting were independently associated with FTR. Hospital volume was not associated with FTR. In AAAA patients hospital volume was significantly associated with a lower adjusted major complication and mortality rate (OR 0.62, 95% CI 0.49-0.78; and 0.64, 95% CI 0.48-0.87). Four hospitals had a significant lower adjusted FTR with different major complication rates on different isomortality lines.

Conclusions: There was more variation in FTR than in mortality between hospitals. FTR identified the same best performing hospitals as for mortality and therefore was of limited additional value in measuring quality of care for AAA surgery. FTR can be used for internal quality improvement with major complications in funnel plots and diagrams with isomortality lines.

Keywords: Abdominal aortic aneurysm; Clinical audit; Composite outcome measures; Failure to rescue; Surgical outcome.

Publication types

Comparative Study

MeSH terms

Aortic Aneurysm, Abdominal / mortality
Aortic Aneurysm, Abdominal / surgery*
Elective Surgical Procedures* / adverse effects
Endovascular Procedures* / adverse effects
Hospital Mortality*
Hospitals
Humans
Netherlands
Postoperative Complications / etiology
Quality Improvement
Time Factors