Death after colectomy: It's later than we think
ABSTRACT Clinical outcomes are increasingly subject to objective assessment and professional accountability. Informed consent relies on accurate estimation of operative risk. Current scoring systems for assessment of operative mortality after colorectal surgery (CRS) almost uniformly report 30-day mortality and may not represent true risk.
University-affiliated Veterans Affairs Medical Center.
All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006.
Mortality at 30 days and 90 days.
The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively.
The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.
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ABSTRACT: Abstract Objective The prognosis for colorectal cancer (CRC) is less favourable in Denmark than in neighbouring countries. To improve cancer treatment in Denmark, a National Cancer Plan was proposed in 2000. We conducted this population-based study to monitor recent trends in CRC survival and mortality in four Danish counties. Method We used hospital discharge registry data for the period January 1985–March 2004 in the counties of north Jutland, Ringkjøbing, Viborg and Aarhus. We computed crude survival and used Cox proportional hazards regression analysis to compare mortality over time, adjusted for age and gender. A total of 19 515 CRC patients were identified and linked with the Central Office of Civil Registration to ascertain survival through January 2005. Results From 1985 to 2004, 1-year and 5-year survival improved both for patients with colon and rectal cancer. From 1995–1999 to 2000–2004, overall 1-year survival of 65% for colon cancer did not improve, and some age groups experienced a decreasing 1-year survival probability. For rectal cancer, overall 1-year survival increased from 71% in 1995–1999 to 74% in 2000–2004. Using 1985–1989 as reference period, 30-day mortality did not decrease after implementation of the National Cancer Plan in 2000, neither for patients with colon nor rectal cancer. However, 1-year mortality for patients with rectal cancer did decline after its implementation. Conclusion Survival and mortality from colon and rectal cancer improved before the National Cancer Plan was proposed; after its implementation, however, improvement has been observed for rectal cancer only.Colorectal Disease 03/2007; 9(3). DOI:10.1111/j.1463-1318.2006.01130.x · 2.02 Impact Factor
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ABSTRACT: Studies of preoperative cardiopulmonary exercise testing (CPET) have shown that a reduced oxygen uptake at anaerobic threshold (AT) and elevated ventilatory equivalent for carbon dioxide (VE/VCO(2)) were associated with reduced short- and medium-term survival after major surgery. The aim of this study was to determine the relative values of these, and also clinical risk factors, in identifying patients at risk of death after major intra-abdominal, non-vascular surgery. Patients aged >55 yr, undergoing elective colorectal resection, radical nephrectomy, or cystectomy between June 2004 and May 2009 had CPET during their routine pre-assessment clinic visit. We performed a retrospective analysis of known clinical risk factors and data from CPET to assess their relationship to all-cause mortality after surgery. Eight hundred and forty-seven patients underwent surgery, of whom 18 (2.1%) died. A clinical history of ischaemic heart disease (RR 3.1, 95% CI 1.3-7.7), a VE/VCO(2) >34 (RR 4.6, 95% CI 1.4-14.8), and an AT < or =10.9 ml kg(-1) min(-1) (RR 6.8, 95% CI 1.6-29.5) were all significant predictors of all-cause hospital and 90 day mortality. The effect of reduced AT was most pronounced in patients with no history of cardiac risk factors (RR 10.0, 95% CI 1.7-61.0). The routine measurement of AT and VE/VCO(2) using CPET for patients undergoing high-risk surgery can accurately identify the majority of high-risk patients, while the use of clinical risk factors alone will only identify a relatively small proportion of at-risk patients.BJA British Journal of Anaesthesia 09/2010; 105(3):297-303. DOI:10.1093/bja/aeq128 · 4.35 Impact Factor
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ABSTRACT: Mortality is widely used to assess quality of hospital care. Inpatient mortality is easily available in administrative data. The use of periods other than length of stay is questionable. We compared different overlapping and disjunctive periods for the calculation of mortality associated with hospital care. Information from public quality reports covering insured from local sickness funds were retrospectively recorded. Nineteen thousand eight hundred thirteen patients from 69 hospitals were included for 5 tracers. The relationship between different periods, or time spans from admission to death or discharge, was assessed calculating the nonparametric correlation coefficient for mortality rates and standardized mortality ratios. The periods were hospital stay, 30, 90, and 365 days after admission, 31 to 90 days, and 91 to 365 days. The variation within each period was assessed with the coefficient of variation. There is a strong relationship between overlapping periods for nonsurgical tracers with r > 0.559 (P < .001). The surgical tracers present a reverse relationship between 30-day and 91-day to 365-day mortality with r = -0.724 (P = .012) for colorectal carcinoma with operation and r = -0.490 (P = .028) for total hip replacement in case of femur fracture. Nonsurgical tracers show a decreasing variation of mortality rates with extending periods, whereas colorectal carcinoma shows a stable and small variation. For nonsurgical tracers, hospital stay is the best period to assess mortality associated with hospital stay. The courses (sequences of 4 mortality rates for one tracer in a hospital) for surgical tracers, in particular colorectal carcinoma, appear as a harvesting effect with an association of high in-hospital mortality with low mortality in the medium term.Quality management in health care 01/2011; 20(3):198-206. DOI:10.1097/QMH.0b013e318223d00a