APPROACH

2. APPROACH • Traditional assessment of complications • Evolution of “Failure to Rescue” concept • Rationale for FTR • Reported applications of FTR • Limitations • STS development of FTR measures

3. APPROACH • Traditional assessment of complications • Evolution of “Failure to Rescue” concept • Rationale for FTR • Reported applications of FTR • Limitations • STS development of FTR measures

4. Definition Mortality rate of patients having experienced a complication or a group of complications

5. Med Care 1992;30:615-29

6. FTR Publications

7. ElementsofFTR Measure • Population • Complication • Outcome • Data • Source : Clinical or Administrative Data • Analysis : Raw Data or Risk-adjusted Data

8. APPROACH • Traditional assessment of complications • Evolution of “Failure to Rescue” concept • Rationale for FTR • Reported applications of FTR • Limitations • STS development of FTR measures

9. Why consider FTR ? • Complication rate may not reflect quality • Under-reporting of complications • Traditional outcomes : patient-related • Measures quality of ICU care • Timely recognition • Effective management

10. APPROACH • Traditional assessment of complications • Evolution of “Failure to Rescue” concept • Rationale for FTR • Reported applications of FTR • Limitations • STS development of FTR measures

11. Population : Cholecystectomy, TURP Complication : Array of complications Outcome : Death Data : Administrative (Medicare) No risk-adjustment

12. Population : Congenital cardiac surgery Complication : 34 postop complications Outcome : Death Data : Clinical No risk-adjustment

13. Population : Adult cardiac surgery Complication : 17 postop complications Outcome : Death Data : Clinical No risk-adjustment

14. Population : General, vascular surgery Complication : 15 postop complications Outcome : Death Data : Clinical (NSQIP) No risk-adjustment

15. Population : Major lung resection Complication : 12 postop complications Outcome : Death Data : Clinical Risk-adjustment

16. Consensus Comparing the best-performing hospitals to the worst-performing hospitals : Complication rates were similar FTR rates were significantly different

17. APPROACH • Traditional assessment of complications • Evolution of “Failure to Rescue” concept • Rationale for FTR • Reported applications of FTR • Limitations • STS development of FTR measures

18. Limitations • Administrative data • No risk-adjustment • Some patients may refuse treatment • Multiple complications • Sequence of complications • Accountability • Surgeon • ICU team • Nurses • Hospital Administration

19. APPROACH • Traditional assessment of complications • Evolution of “Failure to Rescue” concept • Rationale for FTR • Reported applications of FTR • Limitations • STS development of FTR measures

20. STS FTR Measure

21. Participant Sites

23. CompositeMeasure • Perioperative Care • Preop beta-blockers • Discharge beta-blockers • Discharge antiplatelet • Dischageantilipid • Intraoperative Care • Use of IMA • Risk-adjusted Mortality • Operative mortality • Risk-adjusted Morbidity • Prolonged intubation • Mediastinitis • CVA • Renal failure • reoperation Composite Complications

24. STS FTR Measure Population : CABG in 2012 Complication : 5 postop complications Outcome : Death Data : Clinical No risk-adjustment

25. STS FTR Measure The mortality rate for 2012 CABG patients that had any of the 5 composite complications.

26. STS FTR Measure • Procedures : 146,281 • Operative Mortality : 2.0% • Any composite complication : 5.8% • No composite complication : 94.2%

27. Incidenceof Complications

28. Mortalityof Complications

29. MortalityCABG in 2012 Any composite complication Mortality No composite complication Overall

30. 2012 CABGOverall Data • Operative Mortality : 2.0% • Any composite complication : 5.8% • Failure to Rescue : 11.2%

31. Next Steps

32. 2010-2012 CABG • 1,085 sites • 457,795 operations • 62,280 had 1 of the 5 complications

33. Mortalityof Complications

34. Mortalityby Number of Complications % Mortality 1 2 3 4 Number of Complications

35. ImpactofCombinations

36. 2010-2012 CABG Center-level Data • Operative Mortality : • Any composite complication : • Failure to Rescue :

37. CABG MortalityCenters Grouped by Category Calculate operative mortality for each center Arrange in ascending order Low Medium High Divide into groups of equal size

38. CABG MortalityCenters Grouped by Category Low Medium High Complication rate FTR Complication rate FTR Complication rate FTR

39. Center-level FTR

40. CABG MortalityCenters Grouped by Category Low Medium High Complication rate 13% FTR 10% Complication rate 12% FTR 6% Complication rate 16% FTR 14%

41. Complication vs FTR % CABG Mortality Group Unadjusted Data

42. STS FTR Measure Risk Adjustment : Mortality model based on the population that experienced one of the composite complications Risk-adjusted CABG FTR

43. Center-level FTR

44. Volume-Based FTR

45. Complication vs FTR % CABG Mortality Group Unadjusted Data

46. Next Next Steps

47. Reduce FTR • FTR is a reflection of quality • Renal Failure has the highest mortality • Mortality linked to number of complications • Volume plays minimal role in reducing FTR • Addition of prolonged ventilation markedly increases mortality

48. Williams CollegeCommencement Address3 June 2012

49. Williams CollegeCommencement Address3 June 2012 You will have failures. What will define you is not the fact that you failed, but how you respond to the failure.