Higher failure to rescue rates for open aortic surgery in hospitals with more uninsured patients

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As the US Congress debates funding Medicaid and the uninsured, a new vascular study finds that hospitals with a high ratio of those two patient groups are less able to save patients who develop serious surgical complications.

As reported in the August, 2017 edition of the Journal of Vascular Surgery, hospitals with a higher ratio of uninsured/Medicaid patients have a higher “failure to rescue” (FTR) rate for open aortic surgery even after controlling for other factors.

Failure to rescue is defined as the inability to prevent death after a complication develops. Previous studies have examined the association between FTR and “safety-net burden,” (a hospital’s volume of uninsured and Medicaid patients) but none have looked at aortic surgery, or included patient comorbidities in the risk adjustment.

The complex relationship between hospitals with a high percentage of Medicaid patients and the uninsured and FTR following aortic surgery was analysed by a collaborative team of researchers from the Department of Anesthesiology and Division of Vascular Surgery at UT Southwestern in Dallas, USA, led by Eric Rosero.

After adjusting for patient demographics and co-morbidities, they found that the safety-net burden correlates with an increase in the FTR rate observed after major complications.  Importantly, neither hospital volume, resources or technology could explain this effect.

“The observation that increasing safety-net burden was associated with an increasing rate of FTR after open aortic surgery has significant healthcare policy implications,” notes Rosero. “Although failure to rescue is an Agency for Healthcare Research and Quality Patient Safety Indicator, safety-net burden is not currently considered in the risk adjustment for this indicator. As such, calculations of FTR rates may be biased against hospitals that treat a disproportionate number of uninsured or Medicaid patients.”

Using the Nationwide Inpatient Sample, the team studied 47,233 cases performed at 1,777 hospitals in the USA. The multivariable results found that overall, safety-net burden was significantly and independently associated with the increased likelihood of failure to rescue.

For open aortic surgery, the study found that hospital volume was not significantly associated with FTR, but that hospital size did matter. The smallest hospitals had a 37% higher likelihood of FTR.

An increase in hospital volume correlates with a decrease in failure to rescue rates; but an increase in the safety-net burden increases failure to rescue.

Open aortic surgery in an elderly population is a prime example of the challenges vascular surgeons face in minimising variability in healthcare delivery.  Recent studies suggest that failure to rescue is a major contributor to variability observed after complex surgical procedures.

The evidence strongly suggests that there are characteristics of the uninsured or Medicaid populations, or of the hospitals that treat these patients, which predispose to FTR.

The relationship with safety-net burden is poorly understood but likely relates to the clinical challenges of the uninsured patient whose comorbid conditions are often undiagnosed, inadequately treated, or clinically advanced because of issues with access to care and compliance.

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