Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

T. Ahmad, R. A. Bouwman, I. Grigoras, C. Aldecoa, C. Hofer, A. Hoeft, P. Holt, L. A. Fleisher, W. Buhre, R. M. Pearse*, Marissa Ferguson, Michael MacMahon, Mark Shulman, Ritchie Cherian, Helen Currow, Kathirgamanathan Kanathiban, David Gillespie, Edward Pathmanathan, Katherine Phillips, Jenifer ReynoldsJoanne Rowley, Jeanene Douglas, Ross Kerridge, Sameer Garg, Michael Bennett, Megha Jain, David Alcock, Nico Terblanche, Rochelle Cotter, Kate Leslie, Marcelle Stewart, Nicolette Zingerle, Antony Clyde, Oliver Hambidge, Adam Rehak, Sharon Cotterell, Wilson Binh Quan Huynh, Timothy McCulloch, Erez Ben-Menachem, Thomas Egan, Jennifer Cope, Richard Halliwell, Paul Fellinger, Markus Haisjackl, Simone Haselberger, Caroline Holaubek, Paul Lichtenegger, Florian Scherz, Werner Schmid, Franz Hoffer, Int Surgical Outcomes Study ISOS

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Background. The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems.

Methods. We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest).

Results. A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a threefold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failureto- rescue, indicating differences between hospitals in the risk of death among patients after they develop complications.

Conclusions. Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.
Original languageEnglish
Pages (from-to)258-266
Number of pages9
JournalBritish Journal of Anaesthesia
Issue number2
Publication statusPublished - Aug 2017


  • postoperative care, methods
  • postoperative care, statistics and numerical data
  • surgical procedures, operative, mortality

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