Elliot Wakeam, Nathanael D. Hevelone, Rebecca Maine, Jabaris Swain, Stuart A. Lipsitz, Samuel Finlayson, Stanley W. Ashley, and Joel S. Weissman
E. Wakeam, N. D. Hevelone, R. Maine et al., "Failure to Rescue in Safety-Net Hospitals: Availability of Hospital Resources and Differences in Performance," JAMA Surgery, published online Jan. 15, 2014.
Hospitals serving larger proportions of Medicaid and uninsured patients than other hospitals were found to have significantly higher “failure-to-rescue” rates for surgical patients experiencing postoperative complications. This disparity in mortality could not be explained by hospitals’ differing access to sophisticated clinical technology or other resources.
The “failure-to-rescue” indicator is increasingly being used to assess the quality of hospital care. For their Commonwealth Fund–supported study, researchers explored the relationship between failure-to-rescue rates and hospitals’ safety-net burden, which they define as the proportion of patients who are insured by Medicaid or uninsured. The study also examined whether the availability of certain clinical resources, like registered nurses and dvanced technology, affected the relationship between hospitals’ safety-net burden and their failure-to-rescue rates.
This study found significant variation in surgical safety at hospitals with high, moderate, and low proportions of safety-net patients. Though this variation does not appear to relate to hospitals’ access to clinical resources, it may be affected by differences in work culture, operational approach, or other factors. With the expansion of Medicaid under the Affordable Care Act, safety-net hospitals will play an even greater role in providing access to care to low-income and other vulnerable patients. It may be important, the authors say, for safety-net facilities to focus on failure-to-rescue rates in their benchmarking and quality improvement activities.
The study classified hospitals’ safety-net burden by the proportion of Medicaid or uninsured patients they serve, dividing them into three categories: those with low burdens (bottom quartile), moderate burdens (middle two quartiles), and high burdens (top quartile). Using data from the Nationwide Inpatient Sample, the researchers calculated complication rates for 163,963 patients who had undergone one of eight high-risk surgeries. They used American Hospital Association survey data to assess whether hospitals had 14 different types of clinical resources, such as advanced cardiology and endoscopy tools, which may affect their ability to rescue patients in distress.
For reasons that are unclear, hospitals with large proportions of Medicaid and uninsured patients appear to have higher mortality rates among surgical patients experiencing postoperative complications, compared with facilities with low proportions of such patients.