Variation in Hospital Performance for General Surgery in Younger and Older Adults: A Retrospective Cohort Study.

Abstract

To compare hospital surgical performance in older and younger patients. In-hospital mortality after surgical procedures varies widely between hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown. We performed a retrospective cohort study of patients ≥18 years undergoing one of ten common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into two populations: Medicare ≥65 (older adult) and non-Medicare <65 (younger adult) patients. Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population. We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs. 29.8%; P=0.059) and significantly higher failure-to-rescue rates (16.0% vs. 4.0%; P<0.001). Among younger adults, high- relative to low-mortality hospitals had higher complication (15.4% vs. 12.1%; P<0.001) and failure-to-rescue rates (8.3% vs. 0.7%; P<0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 (P<0.001). High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes.