Newly Published
Perioperative Medicine  |   February 2017
Association of the Hospital Volume of Frail Surgical Patients Cared for with Outcomes after Elective, Major Noncardiac Surgery: A Retrospective Population-based Cohort Study
Author Notes
  • From the Department of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada (D.I.M., G.L.B.); Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.I.M.); Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada (D.N.W.); The Ottawa Hospital, Ottawa, Ontario, Canada (A.H.); and Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada (C.v.W.).
  • Corresponding article on page XXX.
    Corresponding article on page XXX.×
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication May 18, 2016. Accepted for publication December 27, 2016.
    Submitted for publication May 18, 2016. Accepted for publication December 27, 2016.×
  • Research Support: Supported by the Canadian Anesthesiologists’ Society Dr. RA Gordon Research Award for Innovation in Patient Safety (Toronto, Ontario, Canada), Department of Anesthesiology, University of Ottawa (Ottawa, Ontario, Canada). This study was also supported by the Institute for Clinical Evaluative Sciences (ICES, Toronto, Ontario, Canada), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. These data sets were held securely in a linked, deidentified form and analyzed at the Institute for Clinical Evaluative Sciences (Ottawa, Ontario, Canada). The funders played no role in study design, execution, or reporting.
    Research Support: Supported by the Canadian Anesthesiologists’ Society Dr. RA Gordon Research Award for Innovation in Patient Safety (Toronto, Ontario, Canada), Department of Anesthesiology, University of Ottawa (Ottawa, Ontario, Canada). This study was also supported by the Institute for Clinical Evaluative Sciences (ICES, Toronto, Ontario, Canada), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. These data sets were held securely in a linked, deidentified form and analyzed at the Institute for Clinical Evaluative Sciences (Ottawa, Ontario, Canada). The funders played no role in study design, execution, or reporting.×
  • Competing Interests: No authors declare any relevant conflicts of interest within the past 36 months.
    Competing Interests: No authors declare any relevant conflicts of interest within the past 36 months.×
  • Correspondence: Address correspondence to Dr. McIsaac: Department of Anesthesiology, Room B311, Civic Campus, The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada. dmcisaac@toh.ca. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine
Perioperative Medicine   |   February 2017
Association of the Hospital Volume of Frail Surgical Patients Cared for with Outcomes after Elective, Major Noncardiac Surgery: A Retrospective Population-based Cohort Study
Anesthesiology Newly Published on February 9, 2017. doi:10.1097/ALN.0000000000001536
Anesthesiology Newly Published on February 9, 2017. doi:10.1097/ALN.0000000000001536
Abstract

Background: Frailty is a risk factor for adverse postoperative outcomes. Hospitals that perform higher volumes of surgery have better outcomes than low-volume providers. We hypothesized that frail patients undergoing elective surgery at hospitals that cared for a higher volume of similarly frail patients would have improved outcomes.

Methods: We conducted a retrospective, population-based cohort study using linked administrative data in Ontario, Canada. We identified all adult major, elective noncardiac surgery patients who were frail according to the validated Johns Hopkins Adjusted Clinical Groups (ACG®) frailty-defining diagnoses indicator. Hospitals were categorized into frailty volume quintiles based on volumes of frail surgical patients cared for. Multilevel, multivariable modeling measured the association of frailty volume with 30-day survival (primary outcome), complications, failure to rescue (secondary outcomes), and costs (tertiary outcome).

Results: Of 63,381 frail patients, 708 (1.1%) died after surgery. The thirty-day mortality rate in the lowest volume quintile was 1.1% compared to 0.9% in the highest. After adjustment for surgical risk, demographic characteristics, comorbidities, and clustering within hospitals, we found a significant association between frailty volume and improved survival (highest volume vs. lowest volume quintile: hazard ratio 0.51; 95% CI, 0.35 to 0.74; P < 0.0001). Although complication rates did not vary significantly between hospitals, failure-to-rescue rates were inversely related to volume.

Conclusions: Frail patients have reduced survival and increased failure to rescue when they undergo operations at hospitals having a lower volume of frail surgical patients. Concentration of perioperative care in centers that frequently treat high-risk frail patients could improve population outcomes.