• Niki Lijftogt, Eleonora G Karthaus, Anco Vahl, Erik W van Zwet, Esmee M van der Willik, Robertus A E M Tollenaar, Jaap F Hamming, Wouters Michel W J M MWJM Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Surgery, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlan, Dutch Society of Vascular Surgery, Steering Committee of the Dutch Surgical Aneurysm Audit, and Dutch Institute for Clinical Auditing.
• Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands. Electronic address: n.lijftogt@gmail.com.
• Eur J Vasc Endovasc Surg. 2018 Nov 1; 56 (5): 652-661.

ObjectivesFailure to rescue (FTR) is a composite quality indicator, defined as the proportion of deceased patients following major complications. The aims of this study were to compare FTR with mortality for hospital comparisons in abdominal aortic aneurysm (AAA) surgery in The Netherlands and investigate hospital volume and associated factors.MethodsPatients prospectively registered between 2013 and 2015 in the Dutch Surgical Aneurysm Audit (DSAA) were analysed. FTR was analysed for AAA patients and subgroups elective (EAAA) and acute (AAAA; symptomatic or ruptured) aneurysms. Variables and hospital volume were analysed by uni- and multivariable regression analysis. Adjusted hospital comparisons for mortality, major complications, and FTR were presented in funnel plots. Isomortality lines were constructed when presenting FTR and major complication rates.ResultsA total of 9258 patients were analysed in 61 hospitals: 7149 EAAA patients (77.2%) and 2109 AAAA patients (22.8%). There were 2785 (30.1%) patients with complications (unadjusted range 5-65% per hospital): 2161 (77.6%) with major and 624 (28.4%) patients with minor complications. Overall mortality was 6.6% (adjusted range 0-16% per hospital) and FTR was 28.4% (n = 613) (adjusted range 0-60% per hospital). Glasgow Coma Scale, age, pulse, creatinine, electrocardiography, and operative setting were independently associated with FTR. Hospital volume was not associated with FTR. In AAAA patients hospital volume was significantly associated with a lower adjusted major complication and mortality rate (OR 0.62, 95% CI 0.49-0.78; and 0.64, 95% CI 0.48-0.87). Four hospitals had a significant lower adjusted FTR with different major complication rates on different isomortality lines.ConclusionsThere was more variation in FTR than in mortality between hospitals. FTR identified the same best performing hospitals as for mortality and therefore was of limited additional value in measuring quality of care for AAA surgery. FTR can be used for internal quality improvement with major complications in funnel plots and diagrams with isomortality lines.Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

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