Trends and Variations in the Rates of Hospital Complications, Failure-to-Rescue and 30-Day Mortality in Surgical Patients in New South Wales, Australia, 2002-2009 Lixin Ou 1 *, Jack Chen 1 , Hassan Assareh 1 , Stephanie J. Hollis 1 , Ken Hillman 1 , Arthas Flabouris 2 1 Simpson Centre for Health Services Research, South Western Sydney Clinical School & Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia, 2 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia, Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, Australia Abstract Background: Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator. Methods: We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics. Results: The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state- level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30- day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group. Conclusions: The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities. Citation: Ou L, Chen J, Assareh H, Hollis SJ, Hillman K, et al. (2014) Trends and Variations in the Rates of Hospital Complications, Failure-to-Rescue and 30-Day Mortality in Surgical Patients in New South Wales, Australia, 2002-2009. PLoS ONE 9(5): e96164. doi:10.1371/journal.pone.0096164 Editor: David W. Dowdy, Johns Hopkins Bloomberg School of Public Health, United States of America Received December 5, 2013; Accepted April 3, 2014; Published May 1, 2014 Copyright: ß 2014 Ou et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The study was funded by grant (APP1009916 & APP1020660) from Australian Government National Health and Medical Research Council. web: www. nhmrc.gov.au. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: lixin.ou@unsw.edu.au Introduction The concept of failure-to-rescue (FTR) was first coined by Silber and colleagues in 1992 [1] with the intention of measuring potentially preventable deaths after surgical complications. The concept has been used in the United States (US) as a nursing sensitive indicator by the National Quality Forum [2] and a patient safety indicator (PSI) by the Agency for Healthcare Research and Quality (AHRQ) [3]. While the original concept of FTR covered a wide range of surgical complications, the AHRQ definition focused on surgical patients who developed at least one of six complications during hospitalisation as one of its PSIs: acute renal failure, deep vein thrombosis (and/or pulmonary embolism), pneumonia, sepsis, shock (and/or cardiac arrest), and gastrointes- tinal bleeding (and/or ulcer) [3]. Given the growing recognition of rapid response systems (RRS) for the timely identification and response to in-hospital deteriorating patients, the term of FTR is also used for evaluating the effectiveness of RRSs [4,5]. In this context, the measure of FTR can estimate the entire organization’s ability to prevent avoidable complications such as unexpected cardiac arrest and related deaths for all hospital patients, not just surgical patients [3,6–8]. Over the past decade, FTR has been widely used as one of seventeen patient safety indicators developed by AHRQ for quality measurement and hospital comparison purposes [9–14]. Failure to achieve such targets also carries financial consequences [15]. In the US, the incidence of FTR was PLOS ONE | www.plosone.org 1 May 2014 | Volume 9 | Issue 5 | e96164