Y. Sanaiha1, A. Mantha1, H. Khoury1, S. Rudasill1, H. Xing1, A. L. Mardock1, B. Ziaeian2, R. Shemin1, P. Benharash1 1University Of California – Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Division Of Cardiology,Los Angeles, CA, USA
Introduction: An increasingly utilized metric for assessing hospital quality performance is rescue after complications occur. While hospital safety-net status has been associated with inferior surgical outcomes and higher costs, the mechanism of this discrepancy is not well understood. We hypothesized that discrepant rates of failure to rescue following complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals.
Methods: The 2005-2014 National Inpatient Sample was used to identify adult patients undergoing elective coronary artery bypass graft, and isolated/concomitant valvular operations. Hospitals were stratified into low (LBH), medium (MBH) or high (HBH) burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status defined by the Institute of Medicine. Cardiovascular, respiratory, renal, hemorrhagic, and infectious complication rates were calculated categorically and as a composite variable, minor/major composite comorbidity (MMC). Failure to rescue (FTR) was defined as mortality after occurrence of a complication. Multivariable logistic regression was utilized to perform a risk-adjusted predictive model of complications and FTR. Incremental adjusted cost of MMC was calculated using a linear regression model.
Results:Of an estimated 1,521,129 patients undergoing elective major cardiac operations, 2% experienced mortality while 36.1% suffered MMC. Compared to LBH patients, the HBH cohort was younger (HBH 64.1 vs. 66.7 years, P<0.0001), more commonly female (31.4 vs 30.0%, P<0.0001), and had a higher incidence of diabetes (35.0 vs 29.7%, P<0.0001) and morbid obesity (5.9 vs 3.9%, P<0.0001). As shown in Figure 1, safety net hospitals are at higher odds of several complications, including tamponade and new dialysis, with a concurrent higher risk for complication-related FTR. In contrast, HBH had higher odds of FTR of respiratory complications despite a lower adjusted risk of this complication category. Occurrence of MMC at HBH was associated with a $2,494 higher cost than at LBH, which would result in a cost-savings of 42.5 million for MMC if HBH had comparable costs and complication rates to LBH.
Conclusion:Safety net hospitals were associated with higher FTR after occurrence of cardiovascular and renal complications. Despite elevated odds of septicemia at HBH, rescue of this complication is superior to LBH. Implementation of care-bundles to tackle cardiovascular, respiratory, and renal complications may impact the discrepancy in incidence and rescue of complications at safety-net institutions.
