Ten-Year Trends in Surgical Mortality, Complications, and Failure to Rescue in Medicare Beneficiaries

Brian T. Fry, MS; Margaret E. Smith, MD, MS; Jyothi R. Thumma, MPH; Amir A. Ghaferi, MD, MS; Justin B. Dimick, MD, MPH


Annals of Surgery. 2020;271(5):855-861. 

In This Article

Abstract and Introduction


Objective: To evaluate how changes in complication and failure to rescue rates influence hospitals' postoperative mortality rates.

Summary Background Data: Surgical mortality has declined over the last decade, but the mechanisms underlying these improvements are unknown. Specifically, the relative impact of reducing postoperative complications versus improving "failure to rescue" remains unclear.

Methods: Using Medicare claims data, we performed a retrospective study of abdominal aortic aneurysm repair, pulmonary resection, colectomy, and pancreatectomy patients. We examined risk-adjusted 30-day mortality, serious complications, and failure to rescue for these patients in from 2005 to 2014 (n = 702,268 patients in 3404 hospitals). Hospitals were then stratified into quintiles by their change in mortality over time.

Results: After stratifying by reductions in mortality from 2005 to 2014, the top 20% of hospitals decreased mortality by 37% (9.0%–5.7%, P < 0.001), decreased serious complications by 11% (15.2%–13.5%, P < 0.001), and decreased failure to rescue by 25% (25.2%–18.9%, P < 0.001). In contrast, the bottom 20% of hospitals increased mortality by 12% (6.9%–7.7%, P < 0.001), increased serious complications by 5% (14.6%–15.4%, P < 0.001), and increased failure to rescue by 4% (21.5%–22.3%, P < 0.001). Partitioning of variance demonstrated that decreased failure to rescue explained 64% of improvement in hospitals' mortality over time, whereas decreased serious complications accounted for only 5% of this improvement.

Conclusions: Hospitals with the largest reductions in surgical mortality achieved these improvements primarily through reducing failure to rescue rates and not by reducing serious complication rates. This suggests that hospitals aiming to reduce surgical mortality should engage in efforts focused on improving rescue.


Mortality after major inpatient surgery has declined considerably over the last decade.[1–3] Many quality and policy initiatives have aimed to reduce patient morbidity and mortality, including concentrating selected procedures in high-volume hospitals, increasing surgical subspecialization, and value-based payment.[4–6] Despite widespread adoption of these initiatives, mortality rates have improved in some hospitals more than others.[2,7] Understanding how these positive deviants have reduced mortality offers valuable insight into how to achieve better results at lower performing hospitals.

The mechanisms underlying reductions in surgical mortality over time are largely unexplored. One hypothesis is that a reduction in serious surgical complications may have led to fewer postoperative deaths. Alternatively, hospitals may have become more proficient at rescuing patients from death after a complication occurs, a concept known as failure to rescue. Prior research suggests that higher mortality hospitals have similar complication rates but worse failure to rescue rates when compared with lower mortality hospitals.[7,8] However, the cross-sectional design of these studies limits causal inference. A longitudinal analysis of complications and failure to rescue comparing hospitals with the greatest and least improvements in mortality would yield a better understanding of how to improve surgical mortality.

We sought to identify the hospitals with the greatest improvements in surgical mortality and to determine how these improvements were influenced by reductions in complication and failure to rescue rates. Using national Medicare data for patients undergoing 4 high-risk operations, we analyzed the relationship between hospitals' risk-adjusted mortality, serious complication, and failure to rescue rates from 2005 to 2014.