Of the 978 nationwide hospitals that responded to the 2005 Leapfrog survey, 658 (67%) hospitals routinely performed at least one of six defined high-risk operations and provided information on their compliance with each of the 27 NQF safe practices (). Of these 658 hospitals, 273 (41%) hospitals were fully compliant with NQF safe practices, whereas 385 (59%) hospitals were partially compliant with NQF safe practices. The characteristics of these hospitals are shown in . Hospitals with full NQF compliance were larger based on admission volume, number of beds, procedure volumes for each of the six operations, and were more likely to be members of health system organizations and be located in urban areas as compared with hospitals with partial NQF compliance.
Characteristics of Hospitals (N=658) that Provided Information on Leapfrog Surveys Regarding Compliance with NQF Safe Practices.
Within the 658 hospitals, 79,462 fee-for-service Medicare beneficiaries aged 65–91 underwent one of six high-risk procedures on an elective basis during the study period. The distribution of operations that patients underwent in these hospitals included 5,102 pancreas resections, 3,332 esophageal resections, 2,748 liver resections, 16,732 open AAA repairs, 51,052 colon resections, and 3,919 gastric resections. The characteristics of patients who underwent these six procedures are summarized in . Patient characteristics did not differ significantly based on hospital compliance with NQF safe practices, with the exception that the proportion of black patients varied with the type of procedure.
Characteristics of Patients Undergoing any of the Six High-Risk Procedures, Stratified by Hospital Compliance with NQF Safe Practices
The unadjusted incidence of any complication (complication rate) diagnosed among patients undergoing any high-risk procedure was found to be significantly higher in hospitals with full compliance (12.4% vs. 10.9%; P<0.05) as compared with hospitals with partial compliance (). When stratified by type of high risk procedure, the unadjusted complication rate was found to be higher in hospitals with full vs. partial compliance with the exception of patients undergoing gastrectomy, although these comparisons were not statistically significant for any individual type of operation (). After adjusting for patient and hospital-level covariates in the logistic regression analysis, the likelihood of any postoperative complication was significantly higher in hospitals with full NQF compliance (OR: 1.13; 95%CI: 1.03–1.25) as compared with hospitals with partial compliance ().
Unadjusted Rate of All Complications (A) Failure to Rescue (B) and 30-day Mortality (C) for Patients Undergoing Six High Risk Operations According to Hospital Compliance with National Quality Forum Safe Practices, 2004–2006
Risk-adjusted* Odds of Diagnosis of Complications, Failure to Rescue, and 30-day Mortality Following Six High-Risk Procedures in Hospitals with Full NQF Compliance Compared to Hospitals with Partial NQF Compliance, 2004–2006.
Hospital compliance with individual NQF safe practices did not lead to lower complication rates among the specific events they were designed to prevent(). In fact, hospitals with full compliance were significantly more likely than hospitals with partial compliance in risk-adjusted models to diagnose a deep venous thrombosis (OR: 1.25; 95%CI: 1.05–1.49), postoperative surgical site infection (OR: 1.17; 95%CI: 1.01–1.34), and postoperative cardiac event (OR: 1.15; 95%CI: 1.00–1.34), however other individual complications did not reach statistical significance.
Mean Rate of Postoperative Complications in Hospitals Stratified By Compliance with Individual NQF Safe Practices, 2004–2006.
Despite a higher rate of complications in patients following high-risk procedures, we found that hospitals with full compliance had a significantly lower unadjusted rate of failure to rescue from any complication (7.8% vs. 9.4%; P<0.05) when compared with hospitals with partial compliance (). In analyses stratified by type of operation, an unadjusted lower rate of failure to rescue was observed in hospitals with full compliance following all operations with the exception of patients undergoing hepatectomy (). When analyses were stratified by type of complication, surgical site infections were the only complication with a significant lower failure to rescue in hospitals with full vs. partial compliance (OR: 0.66; 95% CI: 0.49–0.89). In the regression models that controlled for patient and hospital covariates, hospitals with full compliance were significantly less likely to have a mortality associated with any complication (OR: 0.82; 95%CI: 0.71–0.96) as compared with hospitals with partial compliance ().
For patients undergoing any of the high-risk procedures, unadjusted mortality rates were significantly lower among hospitals with full NQF compliance (2.5% vs. 3.1%; P<0.05) as compared with hospitals with partial compliance. A lower unadjusted mortality rate was associated with full compliance in any of the six high-risk procedures (). After adjusting for patient and hospital level covariates in regression models, hospitals with full compliance had significantly lower odds of risk adjusted mortality following any of the procedures (OR: 0.80; 95%CI: 0.71–0.91) when compared with hospitals with partial compliance. The mortality benefit associated with full compliance was significant for every procedure with the exception of hepatectomy and open AAA repair, which trended towards but did not reach statistical significance ().