S. L. Revels1, P. K. Park1, J. D. Birkmeyer2, S. L. Wong1 1University Of Michigan,Ann Arbor, MI, USA 2Dartmouth Medical School,Lebanon, NH, USA
Introduction: Case-fatality and overall mortality rates after major cancer resections vary widely across hospitals. The mechanisms that drive these differences in outcomes are poorly defined. We examined the extent to which the utilization of critical care resources explains disparate outcomes between low mortality hospitals (LMHs) and high mortality hospitals (HMHs).
Methods: All hospitals participating in the National Cancer Database (2006-2007) were ranked on risk-adjusted mortality for major bladder, colon, esophagus, gastric, lung and pancreas cancer resections. Onsite chart reviews were performed at 19 LMHs (risk-adjusted mortality rate 2.4%) and 30 HMHs (risk-adjusted mortality rate 6.7%), abstracting information on perioperative care, complications and mortality. Using logistic regression, differences in complication, case-fatality and mortality rates were examined based on ICU utilization. Models were adjusted for patient factors, tumor characteristics and clustering within hospitals.
Results: Overall, 40% of patients were triaged directly to an ICU following major cancer resection. Relatively few patients were transferred to ICUs after POD 0, with rates of 4.4% in LMHs and 3.8% in HMHs (p=0.27). HMHs admitted 45.7% of patients directly to an ICU postoperatively, significantly more than 32.6% at LMHs (p<0.01). HMHs directly admitted 76.6% of patients with an ASA status of 4 or 5, 60.3% of patients with ischemic heart disease and over 80% of patients undergoing lung, esophagus and pancreas resections to an ICU. After risk-adjustment, the complication rate for HMH ICU direct admits was 31.4% (95%CI, 24.4-38.6%), not significantly different from 25.6% (95%CI, 20.1-30.5%) in LMH direct ICU admits. Conversely, the risk-adjusted case-fatality rate was significantly higher for HMH direct ICU admits compared to those in LMHs, 32.8% (95%CI, 24.5-41.2%) versus 13.8% (95%CI, 8.0-19.5%), respectively. Similarly, risk-adjusted overall mortality for ICU direct admits was significantly higher in HMHs than LMHs, 12.6% (95%CI, 10.1-15.1%) compared to 4.8% (95%CI, 3.2-6.4%), respectively.
Conclusion: Preemptive ICU admission does not assure better outcomes for high risk cancer patients. Despite utilizing critical care resources at substantially higher rates for high risk patients compared to LMHs, HMHs experienced significantly higher case-fatality and overall mortality rates. Understanding the processes and structural aspects of ICU care administered to cancer patients may yield opportunities to improve the quality of cancer surgery.