Mortality Rises With Changes in Urologic Care

The incidence of preventable inpatient deaths associated with common urologic procedures increased significantly over a 12-year period coinciding with a shift of more procedures to the outpatient setting, investigators reported.

Overall mortality remained stable, but deaths attributable to "failure to rescue" (FTR) had an absolute increase of 18% during the study period.

Older, sicker patients had higher FTR rates, as did minorities, publicly insured patients, and patients who received care at urban hospitals. The findings point to opportunities for process improvement initiatives, reported Jesse D. Sammon, DO, of Henry Ford Health System in Detroit, and colleagues in BJU International.

"In the general surgical literature you see a trend toward decreased postoperative mortality," Sammon told MedPage Today. "You also see a decrease in mortality following complications. We expected the same thing in the urologic literature. Instead, we found that the mortality rate overall was stable between 1998 and 2010, but the mortality rate after a complication increased by 1.5% per year over that time period."

Measuring Quality

As a quality metric, FTR began to emerge following publication of the Institute of Medicine report, "To Err is Human," which raised concerns about the safety of hospitalized patients. FTR refers to a provider's ability to recognize complications and intervene before death.

Several recent studies of national trends in surgical outcomes have demonstrated decreased inpatient mortality, including one study that attributed the improvement to a decline in FTR, the authors said.

Numerous studies have examined mortality and FTR rates in high-risk urologic procedures, but no assessment of overall mortality and FTR has encompassed the "breadth of urological surgery," including common nononcologic procedures, they continued.

Following trends toward favorable FTR rates in general surgery, Sammon and colleagues hypothesized that the volume of urologic procedures increased and that both overall mortality and FTR deaths decreased. To test their hypotheses, they analyzed data from the National Inpatient Sample (NIS) for patients who underwent urologic surgery from 1998 through 2010.

The primary outcomes of the analysis were overall mortality, FTR mortality, and the proportion of mortality attributable to FTR, which the authors defined as a complication that "was potentially recognizable/preventable." Complications of interest consisted of sepsis, pneumonia, deep vein thrombosis or pulmonary embolism, shock or cardiac arrest, and upper gastrointestinal bleeding during admission for surgery.

The authors used a published algorithm of preventable adverse events, derived from ICD-9 codes, diagnosis-related groups, and major diagnostic categories.