ASO Author Reflections: Complex Cancer Surgery Mortality After 30 Days: An Opportunity for Improvement
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Complex Cancer Surgery Mortality After 30 Days: An Opportunity for Improvement Benjamin J. Resio, MD1, and Daniel J. Boffa, MD2 Departments of Surgery, Yale University School of Medicine, New Haven, CT; 2Departments of Thoracic Surgery, Yale University School of Medicine, New Haven, CT
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PAST Surgical research and quality improvement have traditionally focused on mortalities occurring within 30 days of surgery.1,2 However, recent studies have shown that a substantial fraction of postsurgical mortalities may occur outside of this 30-day window, especially among complex cancer operations.3,4 Currently, less is known about these ‘‘late’’ postsurgical deaths. We hypothesized that better understanding the circumstances surrounding these deaths may lead us to interventions that will improve postsurgical care.
14.1%) and lobectomy having the smallest (3.6% vs. 7.0%). Most ‘‘late’’ mortality patients had been discharged from the index admission and readmitted (74% readmitted, only 11% died while still within the index admission). According to death certificate information, a sizable percentage died in a nursing home (20%) and few at home (6%). When looking at the ‘‘underlying’’ cause of death, and other contributing causes provided through death certificate data, we found that 56% of both late and early mortalities were attributed to the malignancy itself.5 It seemed that this generalized attribution of cause of death may be obscuring attempts to identify actionable areas for quality improvement.
PRESENT FUTURE We used the Surveillance, Epidemiology, and End Results (SEER) database linked to Medicare claims and the Connecticut Tumor Registry (CTR) database to look at deaths within 90 days of complex cancer surgery (lung, colon, pancreas, stomach, and esophageal resections) from 2004 to 2013. The CTR gave us access to granular information from death certificates, including place of death and multiple, contributing causes of death. We found that nearly half of patients (1367/3091; 44%) who died within 90 days died after the first 30 days. The timing of deaths (early vs. late) within the 90-day period differed strikingly across procedures, with esophagectomy having the largest difference between the 30- and 90-day mortality (5.7% vs.
Ó Society of Surgical Oncology 2020 First Received: 27 July 2020 Accepted: 9 August 2020 B. J. Resio, MD e-mail: [email protected]
Death documentation must improve. Arguably one of the most important endpoints in medicine, the circumstances surrounding the failure of life-saving treatment is among the least well characterized. Efforts must be made to ensure a more uniform death documentation strategy that captures a consistent, clear, and complete depiction of how and why people die. The solution will likely require more than a simple revision of the death certificate used in the USA. New variables, such as cancer trajectory at time of death (e.g., responding to cancer treatment, progressing through cancer treatment, complete remission)
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