Understanding variation in In-hospital mortality after major surgery in the United States

Document Type



Medical College Pakistan


Objective: We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US).
Background: The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multi-factorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown.
Study design: Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006-2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multi-level logistic regression models were constructed using PC, HC and HOV to calculate attributable variability in IHM for each.
Results: 80,969 patients across 1025 hospitals were included. Post-operative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung and rectal surgery. HC accounted for 16.9% and 17.4% of variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups.
Conclusions: Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remain the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM


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Publication (Name of Journal)

Annals of surgery