Relation between general practices' outpatient referral rates and rates of elective admission to hospital.

OBJECTIVE--To examine the variation in rates of admission to hospital among general practices, to determine the relation between referral rates and admission rates, and to assess the extent to which variations in outpatient referral rates might account for the different patterns of admission. DESIGN--A comparison of outpatient referral rates standardised for age and sex and rates of elective admission to hospital for six specialties individually and for all specialties combined. SETTING--19 General practices in three districts in Oxford Regional Health Authority with a combined practice population of 188 610. MAIN OUTCOME MEASURES--Estimated proportion of outpatient referrals resulting in admission to hospital, extent of variation in referral rates and admission rates among practices, and association between admissions and outpatient referrals. RESULTS--Patients referred to surgical specialties were more likely than those referred to medical specialties to be admitted after an outpatient referral. Overall, the estimated proportion of patients admitted after an outpatient referral was 42%. There were significant differences among the practices in referral rates and admission rates for most of the major specialties. The extent of systematic variance in admission rates (0.048) was similar to that in referral rates (0.037). Referral and admission rates were significantly associated for general surgery; ear, nose, and throat surgery; trauma and orthopaedics; and all specialties combined. For most specialties the practices with higher referral rates also had higher admission rates, casting doubt on the view that these practices were referring more patients unnecessarily. CONCLUSION--Rates of elective admission to hospital vary systematically among general practices. Variations in outpatient referral rates are an important determinant of variations in admission rates.     

Increased rates of illness and death from asthma in Canada.

Recent rates of illness and death from asthma in Canada and rates of hospital admission/separation for asthma were examined by age group and region. The death rates were higher in 1982-84 than in 1970-72, especially among those aged 15 to 34 years. Increases were also noted in hospital admission/separation rates, especially among those less than 15 years of age. Hospital admission/separation rates were highest in the Maritime provinces and Saskatchewan, whereas death rates were highest in Alberta and Saskatchewan. Examination of death certificates for coding errors and recoding of certificates to a single (8th) revision of the International Classification of Diseases indicated that changes in disease coding and errors in coding did not account for the significant increase in rates of death from asthma for those aged 15 to 34 years. These increases in rates of illness and death from asthma are unexplained and warrant further investigation.     

Mortality in elderly patients admitted for respite care.

OBJECTIVE--To determine whether admitting elderly patients to hospital to give temporary relief to their carers is associated with increased mortality. DESIGN--Prospective multicentre study comparing the mortality of patients admitted on a one off or rotational basis with that experienced while they were awaiting admission. SETTING--A wide range of urban and rural district general, geriatric or long stay, and general practitioner hospitals. PATIENTS--474 Patients aged 70 or over who had 601 admissions. MAIN OUTCOME MEASURE--Death. RESULTS--16 (3.4%) Of the 474 patients (2.7% of all 601 admissions) died while in hospital during an average stay of 15.7 days whereas 23 (4.9%) patients died while awaiting admission (average waiting time was 34.2 days). The 16 deaths in hospital and the 23 deaths during the longer waiting period correspond to death rates of 19.9 and 12.5 per 10,000 person days respectively. The difference between these of 7.4 is not statistically significant (95% confidence interval -3.6 to 18.3). The estimated relative risk of dying in hospital is 1.59 but the 95% confidence interval is wide (0.84 to 3.01). CONCLUSION--Although the death rates are slightly higher in those admitted to hospital for relief care than in those awaiting admission, the difference was not significant, and the death rate in both groups was reassuringly small.     

Trends in the hospital care of acute childhood asthma 1970-8: a regional study.

In the South-west Thames Region over the period 1970-8 the number of admissions for asthma in children aged 5-14 years increased from 256 to 684, an increase of 167%. Factors associated with this trend were investigated by an analysis of routine hospital statistics and examination of case notes for 1970 and 1978 from every hospital in the region. The trend was caused partly by an increase in readmission rates. There was a more than fivefold increase in self-referrals; these patients had less severe asthma on admission and a higher readmission rate than patients referred by general practitioners. Drug management before and after admission changed considerably over the nine years, as did hospital investigations. Overall, there was little change in the level of severity on admission. The increase in admissions was not associated with a reduction in deaths from asthma in the region and occurred in spite of major advances in the drug control of asthma; this indicates an inadequacy of ambulatory care. The shift in the balance of care towards the hospital and the increasing adoption of a primary care function by the hospital indicate a need for hospitals and general practice to agree jointly on management policies for acute asthma.     

Illness in the family

OBJECTIVE: To update reports of increases in the rates of admission to hospital and death from asthma among children and young adults in Canada during the 1970s by examining data for the 1980s. DESIGN: Age-standardized rates were calculated from data for people less than 35 years of age at the time of death from asthma, bronchitis or other respiratory conditions (from 1980 through 1989) and at the time of admission to hospital for treatment of these diseases (from 1980 through 1988). Standardized mortality ratios were calculated with the death rate for Canada as the expected rate. SETTING: Data for all of Canada were examined by sex, age group and province. RESULTS: In contrast to sharp increases in the rate of death from asthma observed from 1970 through the early 1980s among Canadians less than 35 years of age, the rate showed no net change between 1980 and 1989; on average, there were 58 deaths in this age group annually. During the decade, the rates of death from asthma were three times higher in Saskatchewan and Alberta than in Newfoundland. The national rate of hospital admission/separation for asthma, however, increased greatly, though changes in the rate varied by province. Increases of over 90% were observed in Prince Edward Island and New Brunswick, whereas little overall change occurred in Newfoundland, Manitoba and Saskatchewan. The rate of hospital admission/separation for asthma was highest in Prince Edward Island and lowest in Manitoba and British Columbia. Although the rates of hospital admission/separation for asthma among boys aged less than 15 years of age were consistently 50% higher than those among girls of that age, the rate among people aged 15 through 34 years was twice as high among females as males. A slight decrease in the rates of death from respiratory conditions other than asthma was observed, together with a steady, fairly substantial decline in the rates of hospital admission/separation for these conditions. CONCLUSIONS: Whether there is any relation between increases in rates of admission to hospital for asthma and trends in the rates of death from asthma during the decade will require further study.     

Association between teenage pregnancy rates and the age and sex of general practitioners: cross sectional survey in Trent 1994-7

This cross-sectional study examined variations in teenage pregnancy rates in the Trent region, UK, and determined possible associations with local general practice characteristics such as the age and sex of the doctors. The study sample included all pregnancies of teenagers, aged 13-19 years, between 1994 and 1997 that resulted in a hospital admission. It also included all 826 general practices in the Trent region between 1994 and 1997. Upon a multivariate analysis, lower teenage pregnancy rates were associated with the presence of a female or young doctor and more nurse time. Practices in deprived areas had higher teenage pregnancy rates. Overall, general practices with female doctors, young doctors, or more nurse time had lower teenage pregnancy rates. These findings may have implications for the mix of health professionals within primary care.     

Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study

Objectives To investigate time trends in mortality after admission to hospital for fractured neck of femur from 1968 to 1998, and to report on the effects of demographic factors on mortality.Design Analysis of hospital inpatient statistics for fractured neck of femur, incorporating linkage to death certificates.Setting Four counties in southern England.Subjects 32 590 people aged 65 years or over admitted to hospital with fractured neck of femur between 1968 and 1998.Main outcome measures Case fatality rates at 30, 90, and 365 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results Case fatality rates declined between the 1960s and the early 1980s, but there was no appreciable fall thereafter. They increased sharply with increasing age: for example, fatality rates at 30 days in 1984-98 increased from 4% in men aged 64-69 years to 31% in those aged ≥ 90. They were higher in men than women, and in social classes IV and V than in classes I and II. In the first month after fracture, standardised mortality ratios in women were 16 times higher, and those in men 12 times higher, than mortality in the same age group in the general population.Conclusions The high mortality rates, and the fact that they have not fallen over the past 20 years, reinforce the need for measures to prevent osteoporosis and falls and their consequences in elderly people. Whether post-fracture mortality has fallen to an irreducible minimum, or whether further decline is possible, is unclear.     

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality

Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998.Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates.Setting Southern England.Subjects 5312 people admitted to hospital with acute pancreatitis.Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women.Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.     

Drowning Mortality and Morbidity Rates in Children and Adolescents 0-19yrs: A Population-Based Study in Queensland,Australia

ObjectiveTo redress the lack of Queensland population incidence mortality and morbidity data associated with drowning in those aged 0-19yrs, and to understand survival and patient care.ResultsDrowning death to survival ratio was 1:10, and two out of three of those who survived were admitted to hospital. Incidence rates for fatal and non-fatal drowning increased over time, primarily due to an increase in non-fatal drowning. There were non-significant reductions in fatal and admission rates. Rates for non-fatal drowning that did not result in hospitalisation more than doubled over the seven years. Children aged 5-9yrs and 10-14yrs incurred the lowest incidence rates 6.38 and 4.62 (expressed as per 100,000), and the highest rates were among children aged 0-4yrs (all drowning events 43.90; fatal 4.04; non-fatal 39.85–comprising admission 26.69 and non-admission 13.16). Males were over-represented in all age groups except 10-14yrs. Total male drowning events increased 44% over the seven years (P<0.001).ConclusionThis state-wide data collection has revealed previously unknown incidence and survival ratios. Increased trends in drowning survival rates may be viewed as both positive and challenging for drowning prevention and the health system. Males are over-represented, and although infants and toddlers did not have increased fatality rates, they had the greatest drowning burden demonstrating the need for continued drowning prevention efforts.     

Incidence and Variation of Discrepancies in Recording Chronic Conditions in Australian Hospital Administrative Data

Diagnostic data routinely collected for hospital admitted patients and used for case-mix adjustment in care provider comparisons and reimbursement are prone to biases. We aim to measure discrepancies, variations and associated factors in recorded chronic morbidities for hospital admitted patients in New South Wales (NSW), Australia. Of all admissions between July 2010 and June 2014 in all NSW public and private acute hospitals, admissions with over 24 hours stay and one or more of the chronic conditions of diabetes, smoking, hepatitis, HIV, and hypertension were included. The incidence of a non-recorded chronic condition in an admission occurring after the first admission with a recorded chronic condition (index admission) was considered as a discrepancy. Poisson models were employed to (i) derive adjusted discrepancy incidence rates (IR) and rate ratios (IRR) accounting for patient, admission, comorbidity and hospital characteristics and (ii) quantify variation in rates among hospitals. The discrepancy incidence rate was highest for hypertension (51% of 262,664 admissions), followed by hepatitis (37% of 12,107), smoking (33% of 548,965), HIV (27% of 1500) and diabetes (19% of 228,687). Adjusted rates for all conditions declined over the four-year period; with the sharpest drop of over 80% for diabetes (47.7% in 2010 vs. 7.3% in 2014), and 20% to 55% for the other conditions. Discrepancies were more common in private hospitals and smaller public hospitals. Inter-hospital differences were responsible for 1% (HIV) to 9.4% (smoking) of variation in adjusted discrepancy incidences, with an increasing trend for diabetes and HIV. Chronic conditions are recorded inconsistently in hospital administrative datasets, and hospitals contribute to the discrepancies. Adjustment for patterns and stratification in risk adjustments; and furthermore longitudinal accumulation of clinical data at patient level, refinement of clinical coding systems and standardisation of comorbidity recording across hospitals would enhance accuracy of datasets and validity of case-mix adjustment.     

Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease

Objective To determine whether a nurse led smoking cessation intervention affects smoking cessation rates in patients admitted for coronary heart disease.Design Randomised controlled trial.Setting Cardiac ward of a general hospital, Norway.Participants 240 smokers aged under 76 years admitted for myocardial infarction, unstable angina, or cardiac bypass surgery. 118 were randomly assigned to the intervention and 122 to usual care (control group).Intervention The intervention was based on a booklet and focused on fear arousal and prevention of relapses. The intervention was delivered by cardiac nurses without special training. The intervention was initiated in hospital, and the participants were contacted regularly for at least five months.Main outcome measure Smoking cessation rates at 12 months determined by self report and biochemical verification.Results 12 months after admission to hospital, 57% (n = 57/100) of patients in the intervention group and 37% (n = 44/118) in the control group had quit smoking (absolute risk reduction 20%, 95% confidence interval 6% to 33%). The number needed to treat to get one additional person who would quit was 5 (95% confidence interval, 3 to 16). Assuming all dropouts relapsed at 12 months, the smoking cessation rates were 50% in the intervention group and 37% in the control group (absolute risk reduction 13%, 0% to 26%).Conclusion A smoking cessation programme delivered by cardiac nurses without special training, significantly reduced smoking rates in patients 12 months after admission to hospital for coronary heart disease.     

Trends in deliberate self poisoning and self injury in Oxford, 1976-90.

OBJECTIVE--To review trends in deliberate self poisoning and self injury (attempted suicide) over 15 years (1976-90) on the basis of general hospital referrals. DESIGN--Prospective data collection by computerised monitoring system. SETTING--Teaching general hospital. SUBJECTS--All patients aged 15 and over (n = 9605) referred to the hospital after episodes (n = 13,340) of deliberate self poisoning or self injury. MAIN OUTCOME MEASURES--Rates based on population of Oxford city; changes in substances used for self poisoning; history and repetition of attempts; and rates of admission to the hospital and of referral to the psychiatric service. RESULTS--Attempted suicide rates for women declined during the late 1970s and early 1980s but increased again during the late 1980s. Those for men remained relatively steady throughout the period. Highest mean annual rates occurred in women aged 15-19 (711/100,000) and in 20-34 year old men (334/100,000). The proportion of overdoses with paracetamol increased from 14.3% (125/873) in 1976 to 42% (365/869) in 1990 (chi 2 for trend = 481, p less than 0.01). Throughout the period the proportions of referred patients admitted to hospital and of those attempting suicide for the first time (over two thirds) did not decrease. Annual rates of repetition of attempts by women declined from 15.1% (257/1700) in 1976-8 to 11.9% (161/1356) in 1987-9 (chi 2 for trend = 7.8, p less than 0.01). Lower repetition rates occurred in women admitted to hospital and referred to the psychiatric service (431/4585, 9.4%) than in those not referred (42/235, 17.9%; chi 2 = 17.2, p less than 0.0001). CONCLUSIONS--Rates of attempted suicide declined in the 1970s and early 1980s, in women, but there are probably at least 100,000 hospital referrals a year in England and Wales because of this problem. Prevention of paracetamol self poisoning requires urgent attention, and psychosocial assessment should be conducted with as many of those who attempt suicide as possible.     

Decline in mortality,AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland

Objective To describe changes in demographic factors, disease progression, hospital admissions, and use of antiretroviral therapy in children with HIV.Design Active surveillance through the national study of HIV in pregnancy and childhood (NSHPC) and additional data from a subset of children in the collaborative HIV paediatric study (CHIPS).Setting United Kingdom and Ireland.Participants 944 children with perinatally acquired HIV-1 under clinical care.Main outcome measures Changes over time in progression to AIDS and death, hospital admission rates, and use of antiretroviral therapy.Results 944 children with perinatally acquired HIV were reported in the United Kingdom and Ireland by October 2002; 628 (67%) were black African, 205 (22%) were aged ≥ 10 years at last follow up, 193 (20%) are known to have died. The proportion of children presenting who were born abroad increased from 20% in 1994-5 to 60% during 2000-2. Mortality was stable before 1997 at 9.3 per 100 child years at risk but fell to 2.0 in 2001-2 (trend P < 0.001). Progression to AIDS also declined (P < 0.001). From 1997 onwards the proportion of children on three or four drug antiretroviral therapy increased. Hospital admission rates declined by 80%, but with more children in follow up the absolute number of admissions fell by only 26%.Conclusion In children with HIV infection, mortality, AIDS, and hospital admission rates have declined substantially since the introduction of three or four drug antiretroviral therapy in 1997. As infected children in the United Kingdom and Ireland are living longer, there is an increasing need to address their medical, social, and psychological needs as they enter adolescence and adult life.     

Unemployment rate as predictor of rate of psychiatric admission.

OBJECTIVE--To examine the relation between rates of psychiatric admissions and both the rate of unemployment and the underprivileged area score within small areas. DESIGN--Calculation of correlation coefficients and explanatory power by using data on psychiatric admissions from April 1990 to March 1992. Crude and age standardised rates were used based on all admissions and also on the number of people admitted regardless of the number of times each person was admitted. SETTING--Sectors with an average population of 45,000 consisting of aggregations of neighbouring wards in Bristol and District Health Authority and electoral wards with an average population of 9400 in the city of Bristol. RESULTS--Unemployment rates explained 93% of the variation in the crude person based admission rates standardised for age for those aged under 65 in the sectors. Person based rates correlated more strongly with unemployment than did rates based on all separate admissions. Inclusion of people aged 65 and over weakened the relation. Within electoral wards unemployment rates explained only about 50-60% of the variation but were still more powerful than the underprivileged area score. There was a significant negative correlation between average length of stay and readmission rates--that is, sectors with short lengths of stay were more likely to have patients readmitted (r = -0.64, 95% confidence interval -0.25 to -0.85). CONCLUSIONS--Unemployment rates are an extremely powerful indicator of the rates of serious mental illness that will need treatment in hospital in those aged under 65. This should be considered in the process of resource allocation, particularly to fundholders in general practice, or people with serious mental illness living in areas of high unemployment could be considerably disadvantaged.     

A decade of diabetes: keeping children out of hospital.

OBJECTIVES--To document the number of children aged less than 15 years who developed diabetes and were managed within one large health district, and to evaluate the outcome of those children managed without hospital admission at diagnosis. DESIGN--A retrospective study over 1979-88, when a paediatrician and a physician with special interests in childhood diabetes initiated joint clinics. Data collected from the district diabetes register and files of consultants and health visitors specialising in diabetes. SETTING--Referral of children to consultants in Leicestershire (total population 863,000). MAIN OUTCOME MEASURES--The proportion of children managed without hospital admission, comparison of readmission rates and glycated haemoglobin concentrations between children admitted and those not admitted. RESULTS--Over 10 years 236 children aged 10-14 years developed diabetes (annual incidence rate 12.8/100,000 child population (95% confidence interval 11.3 to 14.7)). In total 138 were not admitted to hospital but received supervised management based at home. Admitted children were younger or acidotic or their family doctors did not contact the diabetes team. Duration of admission declined from seven days in 1979-80 to three days in 1987-8. Ninety two were not admitted to hospital during the 10 years for any reason. Significantly fewer children who received management at home were readmitted for reasons related to diabetes than the group treated in hospital (30 (22%) v 40 (41%); p = 0.004). Concentrations of glycated haemoglobin were no different between the two groups. CONCLUSIONS--Children with newly diagnosed diabetes may be safely and effectively managed out of hospital. Domiciliary or community based management depends on the commitment of consultants specialising in diabetes working in close cooperation with general practitioners, specialist nurses in diabetes, and dietitians.     

Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates

ObjectivesTo calculate socioeconomic and health status measures for the primary care groups in London and to examine the association between these measures and hospital admission rates.DesignCross sectional study.Setting66 primary care groups in London, total list size 8.0 million people.ResultsStandardised hospital admission ratios varied from 74 to 116 for total admissions and from 50 to 124 for emergency admissions. Directly standardised admission rates for asthma varied from 152 to 801 per 100 000 (mean 364) and for diabetes from 235 to 1034 per 100 000 (mean 538). There were large differences in the mortality, socioeconomic, and general practice characteristics of the primary care groups. Hospital admission rates were significantly correlated with many of the measures of chronic illness and deprivation. The strongest correlations were with disability living allowance (R=0.64 for total admissions and R=0.62 for emergency admissions, P<0.0001). Practice characteristics were less strongly associated with hospital admission rates.ConclusionsIt is feasible to produce a range of socioeconomic, health status, and practice measures for primary care groups for use in needs assessment and in planning and monitoring health services. These measures show that primary care groups have highly variable patient and practice characteristics and that hospital admission rates are associated with chronic illness and deprivation. These variations will need to be taken into account when assessing performance.     

Hospital admissions for asthma in east London: associations with characteristics of local general practices,prescribing, and population.

OBJECTIVE: To determine the relative importance of appropriate prescribing for asthma in explaining high rates of hospital admission for asthma among east London general practices. DESIGN: Poisson regression analysis describing relation of each general practice''s admission rates for asthma with prescribing for asthma and characteristics of general practitioners, practices, and practice populations. SETTING: East London, a deprived inner city area with high admission rates for asthma. SUBJECTS: All 163 general practices in East London and the City Health Authority (complete data available for 124 practices). MAIN OUTCOME MEASURES: Admission rates for asthma, excluding readmissions, for ages 5-64 years; ratio of asthma prophylaxis to bronchodilator prescribing; selected characteristics of general practitioners, practices, and practice populations. RESULTS: Median admission rate for asthma was 0.9 (range 0-3.6) per 1000 patients per year. Higher admission rates were most strongly associated with small size of practice partnership: admission rates of singlehanded and two partner practices were higher than those of practices with three or more principals by 1.7 times (95% confidence interval 1.4 to 2.0, P < 0.001) and 1.3 times (1.1 to 1.6, P = 0.001) respectively. Practices with higher rates of night visits also had significantly higher admission rates: an increase in night visiting rate by 10 visits per 1000 patients over two years was associated with an increase in admission rates for asthma by 4% (1% to 7%). These associations were independent of asthma prescribing ratios, measures of practice resources, and characteristics of practice populations. CONCLUSIONS: Higher asthma admission rates in east London practices were most strongly associated with smaller partnership size and higher rates of night visiting. Evaluating ways of helping smaller partnerships develop structured proactive care for asthma patients at high risk of admission is a priority.     

Trends in Severity of Illness on ICU Admission and Mortality among the Elderly

Background

There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU.

Methods

We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission.

Results

Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008.

Conclusion

In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective.     

Trends and Variations in the Rates of Hospital Complications,Failure-to-Rescue and 30-Day Mortality in Surgical Patients in New South Wales,Australia, 2002-2009

Background

Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator.

Methods

We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics.

Results

The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state-level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30-day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group.

Conclusions

The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities.