In-hospital mortality and failure to rescue after cytoreductive nephrectomy

摘要

Background: The risk of in-hospital mortality after cytoreductive nephrectomy (CNT) is non-negligible and may vary widely according to various patient and hospital characteristics and clinical contexts. Objective: To better elucidate the mechanisms underlying variability in operative mortality after CNT. Design, setting, and patients: Using the US-based Nationwide Inpatient Sample registry, a weighted estimate of 16 285 patients with metastatic renal cell carcinoma (mRCC) treated with CNT between 1998 and 2007 was made retrospectively. Outcome measurements and statistical analysis: Failure to rescue (FTR), defined as the number of deaths in patients who developed an adverse outcome during hospitalization. Univariable and multivariable logistic regression models were used. Results: Of all 16 285 mRCC patients who underwent a CNT, 31% had an occurrence of one complication or more. The overall FTR rate was 5% and differed significantly according to age (≥75 yr vs <75 yr: 7.9% vs 4.3%) and comorbidities (≥3 vs 0: 7.7% vs 4.8%), as well as hospital bed size (small vs large: 7.2% vs 5.3%, all p ≤ 0.03). Patients who had an occurrence of infections (19.3%), cardiac- (15.7%), respiratory- (11.4%), or vascular-related complications (16.5%) had significantly higher FTR rates. It is noteworthy that increasing hospital volume and number of hospital beds also corresponded to lower rates of FTR after adjusting for other covariates. Conclusions: Following CNT for mRCC, the occurrence of infections, cardiac-, respiratory-, or vascular-related complications resulted in higher FTR rates. Hospitals with greater number of beds and higher annual hospital volume had lower FTR rates, confirming the concepts that support FTR as an indicator for better quality of care following a high-risk surgical procedure. Crown