多发性并发症对住院手术后抢救失败的影响
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Variation and Impact of Multiple Complications on Failure to Rescue After Inpatient Surgery
背景与目的
研究多种连续性并发症在机体术后死亡率的影响程度。已经提出未能拯救（FTR）作为医院手术死亡率变异的潜在因素。 然而，目前关于FTR发生多种并发症后的医院差异或连续性并发症对变异的作用目前知之甚少。
方 法
对退伍军人事务部外科质量改进计划266101名退伍军人患者的回顾性队列（2000-2014）这些军人有高死亡率住院率，血管或胸腔手术。术后并发症的数量（0,1,2或3）和医院风险调整后死亡率的五分位数之间的30天死亡率用多变量，多级混合效应模型进行评估。
结 果
有并发症的患者中，超过一半（60.9％）有1例，超过1例占63.1％;对于五分位数，并发症没有差异（非常低的死亡率为23.5％ vs 23.6％非常高的死亡率;趋势测试P = 0.15）。 随着并发症的增加，FTR增加（12.0％比18.1％;趋势检验P <0.001），并发症增加（6.7％1并发症vs 26.1％3，最低五分位数; 11.7％1并发症vs 33.0％3，最高五分位数） 然而，与增加并发症相关的FTR风险依然存在整个医院五
五分相对比较稳定，并没有用差异来解释在指数复杂的日子出现多种并发症的患者
结 论
FTR主要发生于并发症发生时具有1个以上剂量 - 反应关系并发症的患者中。 由于这种剂量 - 反应关系在各医院得到了观察，因此改善手术质量的努力可以通过将注意力转移到旨在防止所有医院出现后续并发症的更广泛的干预措施中。
原始文献摘要
Variation and Impact of Multiple Complications on Failure to Rescue After Inpatient Surgery.[J]. Ann Surg 2017;266:59–65
Abstract：
Objective: To examine the extent to which multiple, sequential complications impacts variation in institutional postoperative mortality rates.
Background: Failure to rescue (FTR) has been proposed as an underlying factor in hospital variation in surgical mortality. However, little is currently known about hospital variation in FTR after multiple complications or the contribution of sequential complications to variation.
Methods: Retrospective cohort study of 266,101 patients within the Veterans Affairs Surgical Quality Improvement Program (2000–2014) who underwent a subset of high-mortality inpatient general, vascular, or thoracic procedures. The association between number of postoperative complications (0, 1, 2, or3) and 30-day mortality across quintiles of hospital risk-adjusted mortalitywas evaluated with multivariable, multilevel mixed-effects models.
Results: Among patients who had a complication, over half (60.9%) had 1,
but those with more than 1 accounted for the majority of the deaths (63.1%).Across hospital quintiles, there were no differences in complications (23.5%very low mortality vs 23.6% very high mortality; trend test P ?0.15). FTRincreased significantly (12.0% vs 18.1%; trend test P < 0.001) with an
incremental impact as complications accrued (6.7% 1 complication vs 26.1%3, lowest quintile; 11.7% 1 complication vs 33.0% 3, highest quintile).However, the risk of FTR associated with increasing complications remainedrelatively constant across hospital quintiles and was not explained by differences in patients presenting with multiple complications on the indexcomplicated day.
Conclusions: FTR occurs predominantly among patients who have more than 1 complication with a dose-response relationship as complications accrue. Asthis dose-response relationship is observed across hospitals, surgical quality improvement efforts may benefit by shifting focus to broader interventionsdesigned to prevent subsequent complications at all hospitals.
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