ORIGINAL STUDY
“Failure to Rescue” following Colorectal Cancer Resection
Variation and Improvements in a National Study of Postoperative Mortality
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Cameron I. Wells, MBChB BMedSc(Hons),* Chris Varghese, BMedSc(Hons),*
Luke J. Boyle, MSc,† Matthew J. McGuinness, MBChB,‡
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Celia Keane, MBChB PhD,* Greg O’Grady, MBChB PhD FRACS,*§∥
Jason Gurney, PhD,¶ Jonathan Koea, MD, FACS, FRACS,#
Chris Harmston, FRCS (Eng) FRACS,*‡ and Ian P. Bissett, MD, FRACS*§✉
Objective: To examine variation in “failure to rescue” (FTR) as a driver
of differences in mortality between centres and over time for patients
undergoing colorectal cancer surgery.
Background: Wide variation exists in postoperative mortality following
colorectal cancer surgery. FTR has been identified as an important
determinant of variation in postoperative outcomes. We hypothesized
that differences in mortality both between hospitals and over time are
driven by variation in FTR.
Methods: A national population-based study of patients undergoing
colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand
was conducted. Rates of 90-day FTR, mortality, and complications were
calculated overall, and for surgical and nonoperative complications.
Twenty District Health Boards (DHBs) were ranked into quartiles using
risk- and reliability-adjusted 90-day mortality rates. Variation between
DHBs and trends over the 10-year period were examined.
Results: Overall, 15,686 patients undergoing resection for colorectal
adenocarcinoma were included. Increased postoperative mortality at
high-mortality centers (OR 2.4, 95% CI 1.8–3.3) was driven by higher
rates of FTR (OR 2.0, 95% CI 1.5–2.8), and postoperative complica-
tions (OR 1.4, 95% CI 1.3–1.6). These trends were consistent across
operative and nonoperative complications. Over the 2010 to 2019
period, postoperative mortality halved (OR 0.5, 95% CI 0.4–0.6),
associated with a greater improvement in FTR (OR 0.5, 95% CI
0.4–0.7) than complications (OR 0.8, 95% CI 0.8–0.9). Differences
between centers and over time remained when only analyzing patients
undergoing elective surgery.
Conclusion: Mortality following colorectal cancer resection has halved
over the past decade, predominantly driven by improvements in “rescue”
from complications. Differences in FTR also drive hospital-level varia-
tion in mortality, highlighting the central importance of “rescue” as a
target for surgical quality improvement.
From the *Department of Surgery, The University of Auckland, Auckland,
New Zealand; †Department of Statistics, The University of Auckland,
Auckland, New Zealand; ‡Department of Surgery, Northland District
Health Board, Auckland, New Zealand; §Department of Surgery,
Auckland District Health Board, Auckland, New Zealand; ∥Auckland
Bioengineering Institute, University of Auckland, Auckland,
New Zealand; ¶Department of Public Health, University of Otago
Wellington, Wellington, New Zealand; and #Department of General
Surgery, Waitemata District Health Board, Takapuna, New Zealand.
✉ ian.bissett@auckland.ac.nz.
Data may be obtained from the New Zealand Ministry of Health National
Collections team. Requests can be made by contacting data-enquirie-
s@health.govt.nz. The code used for the analyses in this manuscript is
available from the authors upon reasonable request.
Reported according to the CRediT Author Statement. C.W.: conceptualization,
funding acquisition, methodology, software, formal analysis, writing—original
draft. C.V.: conceptualization, methodology, software, formal analysis, writing
– review and editing. Luke Boyle: methodology, software, formal analysis,
Annals of Surgery  Volume 278, Number 1, July 2023
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Keywords: colorectal cancer, colorectal surgery, failure to rescue, post-
operative complications
(Ann Surg 2023;278:87–95)
T he burden of morbidity and mortality following major col-
orectal cancer resection is substantial, with mortality rates of
1% to 8% reported in the recent literature.1–4 Wide variations in
outcomes exist between hospitals performing colorectal cancer
resections.5–8 In Aotearoa New Zealand, the 2019 Bowel Cancer
Quality Improvement Report found unadjusted 90-day post-
operative mortality ranged from 0% to 7.6% between hospitals.9
Over the last two decades, there have been major changes
in perioperative care, including the adoption of enhanced
recovery programs (ERPs) and minimally invasive surgery,10–12
but also the implementation of other patient safety initiatives
including surgical safety checklists,13,14 early warning scores, and
rapid response teams for deteriorating patients.15 Multiple
studies have demonstrated consistent reductions in postoperative
mortality over the last decade,14,16–18 however, the drivers of
these improvements remain incompletely understood.
Cross-sectional studies have shown that differences in
“rescue” from complications have a stronger association with
hospital-level variation in postoperative mortality than variation
in complication rates.5,19,20 “Failure to rescue” (FTR) is defined
as the rate of death following postoperative complications and is
publicly reported as a hospital quality metric by some organ-
isations, including the Centers for Medicare and Medicaid
Services Hospital Compare program.21,22 FTR has been sug-
gested as a target for quality improvement to reduce variation in
surgical outcomes.23,24 However, few studies have examined how
writing—review and editing. M.McG.: methodology, writing—review and
editing. C.K.: methodology, writing—review and editing. G.O’G.: con-
ceptualization, supervision, writing—review and editing. J.G.: writing—review
and editing. J.K.: writing—review and editing. C.H.: conceptualization,
methodology, supervision, writing—eview and editing. I.B.: conceptualization,
methodology, supervision, writing—review and editing
C.W. is supported by a Health Research Council of New Zealand Clinical
Research Training Fellowship (22/45). There are no other sources of
funding to report for this manuscript.
C.H. and I.P.B. are members of the New Zealand Bowel Cancer Quality
Improvement Group. The other authors report no relevant conflicts of
interest.
Supplemental Digital Content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF ver-
sions of this article on the journal’s website, www.annalsofsurgery.com.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/23/27801-0087
DOI: 10.1097/SLA.0000000000005650
www.annalsofsurgery.com | 87
 Wells et al
longitudinal changes in mortality are driven by FTR and post-
operative complications.4
We hypothesized that hospitals with higher postoperative
mortality would also have higher rates of FTR, and that the
reduction in postoperative mortality over time would be asso-
ciated with improved rates of “rescue”. Therefore, the aims of
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this study were to use a comprehensive national database to: (i)
define the FTR rate following colorectal cancer surgery, (ii)
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examine regional variations in FTR, and (iii) assess FTR as a
driver for reduction in postoperative mortality from 2010
to 2019.
METHODS
Study Design
We undertook a population-based, cohort study of
patients undergoing colorectal cancer resection in Aotearoa New
Zealand from 2010-2019, reported according to the Strengthen-
ing the Reporting of Observational Studies in Epidemiology
(STROBE) statement25 (Appendix 1, Supplemental Digital
Content 1, http://links.lww.com/SLA/E138). Ethical approval
was obtained from the Auckland Health Research Ethics
Committee (AH23701).
Setting and Data Sources
Secondary and tertiary healthcare in Aotearoa New Zea-
land is predominantly delivered through 20 geographically des-
ignated District Health Boards (DHBs) providing publicly
funded care.
Anonymized, linked patient-level data were obtained from
the New Zealand Ministry of Health National Minimum
Dataset (NMDS) and New Zealand Cancer Registry (NZCR).
All publicly-funded hospitalizations are recorded in the NMDS,
including relevant International Classification of Diseases (ICD)
version 10-AM procedure and diagnosis codes.26 Reporting of
new cancer diagnoses to the NZCR is mandatory in New Zea-
land, and the accuracy of this database has previously been
validated.27
Participants
All patients aged over 18 years undergoing colorectal
resection at public hospitals in Aotearoa New Zealand between
January 1, 2010 and December 31, 2019 were identified using
Australian Classification of Health Interventions (ACHI) pro-
cedure codes (Supplementary Table 1, Supplemental Digital
Content 2, http://links.lww.com/SLA/E139). Only the first eligi-
ble operation was included. Patients were required to have an
eligible surgical procedure and general anesthetic code on the
same date. Patients aged <18 years (n = 4), those undergoing
surgery in private hospitals (n = 35), and nonresidents of New
Zealand (n = 14) were excluded. Patients with a routine discharge
(ie, not including patients who died or were transferred to
another hospital) and a length of stay of ≤ 1 day were also
excluded (n = 16), as it was assumed these patients were incor-
rectly coded as having a major colorectal resection.
For inclusion, patients were required to have a new
diagnosis of colorectal cancer (defined as ICD diagnosis codes
C18 and 19 for colon cancer, and C20 for rectal cancer) regis-
tered in the NZCR preoperatively (within 1 year for rectal cancer
or 6 months for colon cancer), or within 2 months following
surgery. Only the first diagnosis of colorectal cancer in the
NZCR since January 1, 1995 was eligible for inclusion; sub-
sequent metachronous colorectal cancer registrations were
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Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 278, Number 1, July 2023
excluded, as was appendiceal carcinoma (C181), and patients
with a cancer diagnosis based on a death certificate only.
Patients with histology codes for neuroendocrine tumors, gas-
trointestinal stromal tumors, lymphomas, squamous cell carci-
nomas, neuroendocrine carcinomas, leiomyosarcomas, and
melanomas were excluded.
Patients undergoing multivisceral resection were excluded;
this was defined as procedure codes for resection of any other
visceral or pelvic organ (other than splenectomy), peri-
tonectomy, or bone resection on the same day as the index
procedure (list of codes in Supplementary Table 2, Supplemental
Digital Content 3, http://links.lww.com/SLA/E140). Codes for
these operations were identified by manual review of all proce-
dures on the same date as the index operation; this was per-
formed by four co-authors (C.W., C.V., M.M., and C.H.) with
consensus achieved by discussion if required.
Variables
Collected data included age at index admission, sex
(categorized as female or male), self-reported ethnicity (priority
coded as Māori, Pacific Peoples, Asian, or European/Other), and
DHB of treatment. The American Society of Anesthesiologists
(ASA) classification score was recorded from the anesthetic
procedure code from the index operation.28 If this was not
available, other anesthetic codes from the previous six months
were examined and the one closest to the index procedure was
used. The NZDep2013 index is an area-level measure of socio-
economic deprivation,29 and was collected for each patient based
on their domiciled address at the time of index surgery, and
categorized as quintiles from 1 (least deprived) to 5 (most
deprived). Tumor location was classified as colon (ICD codes
C18, C19) or rectal (C20), and extent of disease was defined
using the Surveillance Epidemiology and End Results database
coding.30
Comorbidity data were obtained using ICD codes from all
public and private hospital admissions in the NMDS during the
5 years before the index operation.31,32 The cancer-specific C3
comorbidity index was calculated as previously described33,34;
this was used for risk adjustment as it was developed and vali-
dated in the New Zealand population. The C3 Index score was
categorized into discrete groups; “0” ( ≤ 0), “1” ( ≤ 1), “2” ( ≤ 2),
and “3” ( > 2), similar to Gurney et al.35 The predicted 30-day
postoperative mortality was also calculated for each patient
using the NZRISK model, and subsequently used for risk
adjustment. The NZRISK calculation included covariables of
age, sex, ethnicity, acute versus elective admission, and ASA
grade.28 As all patients in this cohort were undergoing major
colorectal cancer resection, the presence of cancer, digestive
surgery, and a surgical severity grade of 4 to 5 were the same for
all patients’ NZRISK calculation.28 This model was developed
and validated in the New Zealand population and is commonly
used by clinicians in Aotearoa New Zealand, making it ideal for
mortality prediction in our cohort.28
Outcomes
The primary outcome of interest was FTR, defined over-
all, and separately for surgical and nonoperative complications.
FTR was defined as 90-day mortality following a complication
(either reoperation, nonoperative complication, or death) within
90 days of surgery. Mortality data were obtained from the
National Health Index (NHI) dataset, linked to the New Zea-
land Register of Births, Deaths, and Marriages. We included
mortality in the definition of “all complications” for the purposes
of the FTR calculation, based on the assumption that all
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
 Annals of Surgery  Volume 278, Number 1, July 2023
postoperative deaths reflect a complication, even if a complica-
tion has not been entered in the administrative coding. To assess
the impact of this assumption, we also performed a sensitivity
analysis without mortality included in the definition of “overall
complications”.
FTR-Surgical (FTR-S) was defined as a 90-day mortality
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following a reoperation within 90 days of surgery.5 Reoperation
was defined as a relevant ACHI procedure code for a gastro-
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intestinal, wound, urinary or vascular procedure from 1 to
90 days after surgery at any public hospital in Aotearoa New
Zealand, with a general anesthetic code on the same date. A list
of relevant procedure codes was developed by manually
reviewing all procedure codes within 90 days of surgery for all
included patients (Supplementary Table 3, Supplemental Digital
Content 4, http://links.lww.com/SLA/E141). Reoperation on the
same day as surgery was not included in this definition as these
codes cannot be distinguished from the index procedure in the
NMDS. Events with codes for ileostomy closure or closure of
laparostomy were excluded from this definition to avoid inad-
vertently capturing patients with a planned return to theatre
(Supplementary Table 3, Supplemental Digital Content 4, http://
links.lww.com/SLA/E141).
FTR-Nonoperative (FTR-NonOp) was defined as a
90-day mortality following a nonoperative complication within
90 days of surgery. Complications were defined using ICD-
10-AM codes and included one or more of; acute kidney injury
(AKI), cardiac arrest, cardiac arrhythmia, myocardial infarc-
tion, sepsis, shock, venous thromboembolism, pneumonia, res-
piratory failure, stroke, or delirium, or 90-day mortality without
a coded complication (Supplementary Table 4, Supplemental
Digital Content 5, http://links.lww.com/SLA/E142). Codes from
the index hospitalization with a diagnosis sequence following the
index surgical procedure, and all subsequent public hospital-
izations within 90-days of surgery were examined for the
occurrence of these complications. Patients who had a reopera-
tion within 90 days of surgery were excluded from both the
numerator and denominator of this calculation.
Secondary outcomes included 30-day, 90-day, and 1-year
postoperative mortality, reoperation, complications, post-
operative length of hospital stay and readmission to any public
hospital in New Zealand within 90 days of surgery. Patients with
admissions that ended in a transfer to another hospital or
inpatient death were excluded from the readmission and length
of stay outcomes.
Missing Data
Data were missing for tumor extent in 2199 (14.0%), ASA
classification in 1510 (9.6%), and NZDep2013 in 5 patients
(0.03%). There were no differences in baseline characteristics and
distribution of outcome and nonoutcome data between the
groups with and without missing data, therefore we assumed
these variables were missing at random. Multiple imputation via
chained equations was used to impute values for patients with
missing data.36 Ten imputed datasets were created and used to fit
separate models. Pooled results were then used for risk and
reliability adjustment.
Statistical Analysis
Baseline categorical data were presented as number and
percentage and analyzed using the independent samples χ2 test.
Continuous data were presented as either mean ± SD or median
and interquartile range, and analyzed using a one-way ANOVA
or Kruskal-Wallis test as appropriate.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Reducing Mortality After Colorectal Surgery
Similar to previously described methods,4,5,37 we devel-
oped risk-adjusted and reliability-adjusted 90-day mortality rates
for each DHB. In brief, a logistic regression model for patient-
level 90-day mortality was developed with adjustment for
NZRISK predicted mortality (which includes age, sex, ethnicity,
acute versus elective surgery, and ASA classification as input
variables), C3 comorbidity index, tumor location, extent of dis-
ease, and NZDep2013 index. A hierarchical mixed-effect logistic
regression model was then used to generate empirical Bayes
predictions of outcomes for each hospital using the methods of
Dimick et al.37,38 This reliability adjustment reduces random
statistical “noise” associated with small sample sizes from some
hospitals, and its importance in ranking of hospitals based on
surgical outcomes has previously been validated.37 Variables
were selected for the multivariate model based on known and
biologically plausible effects on postoperative mortality.39
DHBs were then grouped into quartiles (5 DHBs each)
based on observed versus expected (O/E) risk-adjusted and reli-
ability-adjusted mortality rates. For analysis of changes over
time, patients were grouped into 5 consecutive 2-year time
periods.
Differences between quartiles and time periods were ana-
lyzed using the ordinal chi-squared test for categorical data,40
and 1-way analysis of variance or the Kruskal-Wallis test for
parametric and nonparametric continuous data respectively.
Odds ratios and 95% confidence intervals (CI) were calculated to
compare rates of complications, FTR, and mortality in the
highest- versus lowest-mortality quartiles, and in 2010 to 2011
versus 2018 to 2019. A sensitivity analysis of patients undergoing
elective surgery was undertaken to remove any effect of differ-
ences in emergency presentations between DHBs or over time.
All hypotheses were two-sided with alpha = 0.05. Analyses were
conducted using R version 3.6.1 (R Foundation for Statistical
Computing, Vienna, Austria).
RESULTS
In total, 15,686 patients undergoing colorectal resection
between January 1, 2010 to December 31, 2019 were included
from all 20 DHBs in Aotearoa New Zealand (Fig. 1). Of the
included cohort, 46% were female, with a mean age of 70.9 years
(SD 11.9) (Table 1). Most patients were European/other eth-
nicity (88.5%), and 6.0% were Māori.
Patients from DHBs in the highest-mortality quartile had
higher levels of socioeconomic deprivation, more commonly had
advanced disease, underwent emergency surgery, and had higher
ASA scores (Table 1). Included centers performed median of
70.2 (range 4.8-184.0) colorectal cancer resections per year
during the study period. This varied between O/E mortality
quartiles, with highest mortality quartile DHBs performing
fewer resections per year (P = 0.02) (Table 1).
Postoperative Outcomes
Overall, 30-day and 90-day postoperative mortality rates
were 2.7% (430/15,686) and 4.7% (674/15,686). In elective sur-
gery, this was 1.7% and 2.6% respectively, compared with 6.8%
and 11.2% following emergency surgery. Overall complications
occurred in 32.0% of patients; reoperation within 90 days of
surgery in 8.3%, and nonoperative complications in 23.7%
(Table 2). Reoperations occurred at a median of 8 days (inter-
quartile range 5–18) postoperatively; earlier reoperation was
associated with higher mortality (Supplementary Figure 1,
Supplemental Digital Content 6, http://links.lww.com/SLA/
E143). AKI (9.2%), pneumonia (8.0%), and delirium (7.7%)
www.annalsofsurgery.com | 89
 Wells et al Annals of Surgery  Volume 278, Number 1, July 2023

TABLE 1. Demographic and Clinical Factors, Stratified by O/E DHB Mortality Quartiles
Q1 (Lowest Mortality) Q4 (Highest Mortality)
(n = 3269) Q2 (n = 5741) Q3 (n = 5235) (n = 1441) Overall (n = 15686) P
Patient Data
Female sex 1455 (44.5%) 2669 (46.5%) 2401 (45.9%) 696 (48.3%) 7221 (46.0%) 0.06
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Age
Mean (SD) 70.8 (12.1) 70.5 (12.2) 71.3 (11.7) 71.4 (11.4) 70.9 (11.9) 0.001*
Ethnicity 0.91
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Māori 228 (7.0%) 242 (4.2%) 323 (6.2%) 144 (10.0%) 937 (6.0%) —
Pacific 87 (2.7%) 92 (1.6%) 121 (2.3%) 2 (0.1%) 302 (1.9%) —
Asian 169 (5.2%) 218 (3.8%) 175 (3.3%) 5 (0.3%) 567 (3.6%) —
European/other 2785 (85.2%) 5189 (90.4%) 4616 (88.2%) 1290 (89.5%) 13880 (88.5%) —
NZDep13 Quintile < 0.001*
Q1 (least deprived) 426 (13.0%) 1247 (21.7%) 741 (14.2%) 123 (8.5%) 2537 (16.2%) —
Q2 550 (16.8%) 1305 (22.7%) 810 (15.5%) 179 (12.4%) 2844 (18.1%) —
Q3 714 (21.8%) 1270 (22.1%) 1133 (21.6%) 308 (21.4%) 3424 (21.8%) —
Q4 852 (26.1%) 1276 (22.2%) 1313 (25.1%) 329 (22.8%) 3771 (24.0%) —
Q5 (most deprived) 727 (22.2%) 643 (11.2%) 1238 (23.6%) 502 (34.8%) 3110 (19.8%) —
ASA Classification < 0.001*
1–2 2049 (62.7%) 3503 (61.0%) 3022 (57.7%) 826 (57.3%) 9420 (60.1%) —
3 1127 (34.5%) 2017 (35.1%) 1991 (38.0%) 559 (38.8%) 5670 (36.1%) —
4–5 93 (2.8%) 221 (3.8%) 222 (4.2%) 56 (3.9%) 596 (3.8%) —
C3 Index 0.06
0 1941 (59.4%) 3553 (61.9%) 3101 (59.2%) 825 (57.3%) 9420 (60.1%) —
0–1 471 (14.4%) 763 (13.3%) 740 (14.1%) 213 (14.8%) 2187 (13.9%) —
1–2 342 (10.5%) 582 (10.1%) 537 (10.3%) 168 (11.7%) 1629 (10.4%) —
>2 515 (15.8%) 843 (14.7%) 857 (16.4%) 235 (16.3%) 2450 (15.6%)
Cancer Data
Tumor Location 0.03*
Colonic 2501 (76.5%) 4323 (75.3%) 4048 (77.3%) 1133 (78.6%) 12005 (76.5%) —
Rectal 768 (23.5%) 1418 (24.7%) 1187 (22.7%) 308 (21.4%) 3681 (23.5%) —
Tumor Stage < 0.001*
Localized 1011 (30.9%) 1649 (28.7%) 1653 (31.6%) 398 (27.6%) 4650 (29.6%) —
Invasion of adjacent 722 (22.1%) 1512 (26.3%) 1006 (19.2%) 334 (23.2%) 3556 (22.7%) —
organ
Regional lymph nodes 1218 (37.3%) 2055 (35.8%) 1971 (37.7%) 530 (36.8%) 5856 (37.3%) —
Distant 318 (9.7%) 525 (9.1%) 605 (11.6%) 179 (12.4%) 1624 (10.4%) —
Surgical Data
Elective surgery 2691 (82.3%) 4733 (82.4%) 4028 (76.9%) 1095 (76.0%) 12547 (80.0%) < 0.001*
Hospital Data
Resections per year 0.02*
Median (IQR) 68.2 (38.7) 78.8 (92.0) 113.3 (68.6) 31.2 (22.2) 70.2 (64.6) —
n refers to the number of patients. All quartiles contain 5 DHBs.
*P < 0.05.
IQR indicates interquartile range.

were the most common postoperative complications (Table 3).

The number of complications per patient ranged from 0 to 8;
17.5% of patients had one, 5.8% had two, and 4.4% had three or
more. Mortality was higher amongst patients with multiple
complications (Supplementary Figure 2, Supplemental Digital
Content 7, http://links.lww.com/SLA/E144).
The overall FTR rate was 13.4% (674/5013), FTR-S was
10.2% (132/1299), and FTR-NonOp was 14.6% (542/3714). Of
the 674 deaths within 90 days of surgery, 132 (19.6%) occurred
following a reoperation, and 542 (80.4%) following a non-
operative complication.

Variation between Centers

A marked difference in 30-day (4.0 vs 1.8%, OR 2.20,
95% CI 1.52–3.18) and 90-day (6.7 vs 2.9%, OR 2.44, 95%
CI 1.82–3.26) postoperative mortality rates was observed
between highest-mortality and lowest-mortality DHB quar-
tiles (P < 0.001) (Fig. 2). Highest-mortality DHBs had higher
FIGURE 1. STROBE Flow Diagram. rates of overall complications (36.3 vs 28.6%, OR 1.42, 95%

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 Annals of Surgery  Volume 278, Number 1, July 2023 Reducing Mortality After Colorectal Surgery

TABLE 2. Postoperative Complications and Failure to Rescue Following Colorectal Cancer Resection, Stratified by O/E Mortality
Quartiles
Q1 (Lowest Mortality) Q2 (n = 5741) Q3 (n = 5235) Q4 (Highest Mortality) Overall (n = 15686)
(n = 3269) (%) (%) (%) (n = 1441) (%) (%) P
Overall complication 935 (28.6) 1750 (30.5) 1805 (34.5) 523 (36.3) 5013 (32.0) < 0.001*
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FTR—overall† 94 (10.1) 211 (12.1) 272 (15.1) 97 (18.5) 674 (13.4) < 0.001*
Reoperation 240 (7.3) 427 (7.4) 468 (8.9) 164 (11.4) 1299 (8.3) < 0.001*
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FTR—surgical† 15 (6.2) 44 (10.3) 54 (11.5) 19 (11.6) 132 (10.2) 0.04*

Nonoperative 695 (21.3) 1323 (23.0) 1337 (25.5) 359 (24.9) 3714 (23.7) < 0.001*
complication
FTR—nonOp† 79 (11.4) 167 (12.6) 218 (16.3) 78 (21.7) 542 (14.6) < 0.001*
n refers to the number of patients. All quartiles contain 5 DHBs.
*P < 0.05.
†Failure to rescue rates are calculated using the denominator of patients who experienced a complication, given in the respective rows immediately above.
FTR indicates failure to rescue.

CI 1.25–1.62), reoperation (11.4 vs 7.3%, OR 1.62, 95% CI Improvements in Rescue

1.32–2.00), and nonoperative complications (24.9 vs 21.3%,
OR 1.23, 95% CI 1.06–1.42). However, a larger difference was
observed between highest-mortality and lowest-mortality
DHBs in overall FTR (18.5 vs 10.1%, OR 2.04, 95%
CI 1.50–2.77), FTR-S (11.6 vs 6.2%, OR 1.97, 95% CI 0.98–-
4.0), and FTR-NonOp (21.7 vs 11.4%, OR 2.16, 95%
CI 1.54–3.05). These trends were consistent across
individual complications (Supplementary Figures 3, Supple-
mental Digital Content 8, http://links.lww.com/SLA/E145 and
4, Supplemental Digital Content 9, http://links.lww.com/SLA/
E146).
The 90-day mortality rate halved from 5.8% in 2010 to
2011 to 2.9% in 2018 to 2019 (OR 0.48, 95% CI 0.37–0.62,
P < 0.001; Fig. 3). The rate of overall complications reduced by
3.6% from 2010 to 2011 to 2018 to 2019 (33.2 vs 29.6%, OR 0.84,
95% CI 0.76–0.94). This trend was similar across nonoperative
complications (24.4 vs 22.4%, OR 0.89, 95% CI 0.80–1.01) and
reoperation (8.8 vs 7.2%, OR 0.80, 95% CI 0.66–0.96). The rates
of all complications were either stable or decreased over time,
except for AKI which increased between 2010-11 and 2018-19
(7.1 vs 10.5%, OR 1.54, 95% CI 1.29–1.84, Supplementary
Figures 5, Supplemental Digital Content 10, http://links.lww.

TABLE 3. Postoperative Outcomes Following Colorectal Cancer Resection, Stratified by O/E Mortality Quartiles
Q1 (Lowest Mortality) Q4 (Highest Mortality)
(n = 3269) Q2 (n = 5741) Q3 (n = 5235) (n = 1441) Overall (n = 15,686) P
Complications
Acute Kidney Injury 241 (7.4%) 476 (8.3%) 566 (10.8%) 158 (11.0%) 1441 (9.2%) < 0.001*
Pneumonia 223 (6.8%) 452 (7.9%) 424 (8.1%) 150 (10.4%) 1249 (8.0%) < 0.001*
Delirium 230 (7.0%) 454 (7.9%) 416 (7.9%) 103 (7.1%) 1203 (7.7%) 0.50
Cardiac arrhythmia 192 (5.9%) 359 (6.3%) 410 (7.8%) 117 (8.1%) 1078 (6.9%) < 0.001
Sepsis 137 (4.2%) 220 (3.8%) 286 (5.5%) 111 (7.7%) 754 (4.8%) < 0.001
Respiratory failure 65 (2.0%) 123 (2.1%) 165 (3.2%) 45 (3.1%) 398 (2.5%) < 0.001
Venous 75 (2.3%) 132 (2.3%) 121 (2.3%) 31 (2.2%) 359 (2.3%) 0.86
thromboembolism
Myocardial infarction 37 (1.1%) 98 (1.7%) 98 (1.9%) 28 (1.9%) 261 (1.7%) 0.01*
Stroke 28 (0.9%) 29 (0.5%) 39 (0.7%) 19 (1.3%) 115 (0.7%) 0.16
Cardiac arrest 14 (0.4%) 25 (0.4%) 36 (0.7%) 12 (0.8%) 87 (0.6%) 0.02*
Shock 10 (0.3%) 16 (0.3%) 33 (0.6%) 10 (0.7%) 69 (0.4%) 0.004*
Number of Complications < 0.001*
0 2456 (75.1%) 4233 (73.7%) 3661 (69.9%) 998 (69.3%) 11348 (72.3%)
1 531 (16.2%) 978 (17.0%) 977 (18.7%) 258 (17.9%) 2744 (17.5%)
2 177 (5.4%) 310 (5.4%) 333 (6.4%) 89 (6.2%) 909 (5.8%)
≥3 105 (3.2%) 220 (3.8%) 264 (5.0%) 96 (6.7%) 685 (4.4%)
Time to Reoperation (d) 0.01*
Median (IQR) 9.0 (5.0-20.0) 9.0 (5.0-21.0) 8.0 (4.8-15.0) 7.0 (4.0-11.0) 8.0 (5.0-18.0)
30-day mortality 60 (1.8%) 143 (2.5%) 170 (3.2%) 57 (4.0%) 430 (2.7%) < 0.001*
90-day mortality 94 (2.9%) 211 (3.7%) 272 (5.2%) 97 (6.7%) 674 (4.3%) < 0.001*
1-year mortality 311 (9.5%) 537 (9.4%) 635 (12.1%) 215 (14.9%) 1698 (10.8%) < 0.001*
Postoperative Hospital Stay 0.001
(d)
Median (IQR) 7.0 (5.0-12.0) 7.0 (5.0-11.0) 7.0 (5.0-11.0) 7.0 (5.0-11.0) 7.0 (5.0-11.0)
30-day readmission 464 (15.6%) 904 (17.8%) 861 (19.4%) 248 (19.5%) 2477 (18.0%) < 0.001*
90-day readmission 1127 (37.8%) 1777 (34.9%) 1758 (39.6%) 514 (40.3%) 5176 (37.6%) 0.003*
n refers to the number of patients. All quartiles contain 5 DHBs.
*P < 0.05.
IQR indicates interquartile range.

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Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Wells et al Annals of Surgery  Volume 278, Number 1, July 2023
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FIGURE 2. Rates of mortality, postoperative complications, reoperation, and failure to rescue, stratified by DHB O/E mortality
quartile.

com/SLA/E147 and 6, Supplemental Digital Content 11, http://
links.lww.com/SLA/E148).
In comparison to the modest improvement in complica-
tions, there was a large improvement in overall FTR from 17.1%
to 10.3% over this period (OR 0.51, 95% CI 0.39–0.67,
P < 0.001). This was predominantly driven by an improvement
in FTR-NonOp (19.9 vs 10.3%, OR 0.46, 95% CI 0.34–0.63),
with no significant change in FTR-S (11.0 vs 8.1%, OR 0.71,
95% CI 0.38–1.30). Similar trends were seen for FTR following
individual complications, which showed either stable or declin-
ing rates over the studied period (Supplementary Figures 5,
Supplemental Digital Content 10, http://links.lww.com/SLA/
E147 and 6, Supplemental Digital Content 11, http://links.lww.
com/SLA/E148). Trends in postoperative mortality, FTR, and
complications over time were generally consistent across O/E
mortality quartiles (Supplementary Figure 7, Supplemental
Digital Content 12, http://links.lww.com/SLA/E149).
Sensitivity Analysis
When limiting the cohort to only patients undergoing
elective colorectal cancer resection (n = 12,547, 80% of the total
cohort), there were no major differences to the main results
(Appendix 2, Supplemental Digital Content 13, http://links.lww.
com/SLA/E150). When mortality was excluded from the defi-
nition of overall complications and nonoperative complications,
there were no changes to the findings of the primary analysis
(Appendix 3, Supplemental Digital Content 14, http://links.lww.
com/SLA/E151). The rate of death in patients without a coded
preceding complication or reoperation also varied between high-
and low-mortality DHBs, and over time, suggesting this reflected

FIGURE 3. Changes in the rates of mortality, postoperative complications, reoperation, and failure to rescue over the 2010 to
2019 period.

92 | www.annalsofsurgery.com Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Annals of Surgery  Volume 278, Number 1, July 2023
patients with complications which were not captured by clinical
coding.
DISCUSSION
Stark differences in postoperative mortality following
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colorectal cancer resection exist between hospitals in Aotearoa
New Zealand. This variation is predominantly driven by differ-
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 10/11/2023
ences in rates of “rescue” from both operative and nonoperative
complications, with a smaller contribution from variation in the
rate of complications. Postoperative mortality following color-
ectal cancer resection has halved over the past decade, pre-
dominantly driven by improvements in FTR-NonOp, with no
difference in FTR-S and only minor reductions in the compli-
cation rate. These findings highlight that quality improvement
initiatives should target FTR to improve surgical outcomes, in
addition to interventions aiming to reduce postoperative
complications.
FTR was first described by Silber et al in 1992,41 but its
importance as a determinant of hospital variation in post-
operative mortality was highlighted by Ghaferi et al19 in a
seminal paper from 2009. FTR has since been consistently
demonstrated as a determinant of hospital-level variation in
postoperative mortality,5,19,20 in keeping with our findings.
However, few studies have examined rates of FTR over time and
their contribution to longitudinal improvements in postoperative
mortality. Fry et al4 previously used Medicare data to compare
rates of mortality and FTR in 2005 to 2006 versus 2013 to 2014,
and showed rescue explained 64% of the improvement in post-
operative mortality, compared with postoperative complications
which only explained 5%.In their Medicare dataset, 30-day
postoperative mortality following colectomy reduced from 9.7%
to 8.7% from 2005 to 2006 to 2013 to 2014, predominantly
driven by an improvement in FTR from 25.2% to 22.7%, with
major complications increasing from 16.1% to 16.6%.41 These
results are generally consistent with our finding that FTR is the
primary driver of improvements in postoperative mortality, but
contrast with the much larger improvements in both post-
operative mortality and FTR in our cohort. Improvements in
FTR-NonOp were the primary driver of reductions in mortality
in the present study, with no significant change in FTR-S over
time. In contrast, Tran et al42 showed reductions in both reop-
eration and FTR-S following cardiac surgery from 2005-18, but
did not examine the contribution of nonoperative complications.
Although improving outcomes after surgery is complex,
improvements in FTR appear to have a substantial effect on
reducing postoperative mortality.
Multiple changes in perioperative care may have con-
tributed to these improvements in postoperative mortality and
rescue, including the national implementation of the standard-
ized New Zealand early warning scores, critical care outreach
and rapid response teams,15,43 use of surgical safety checklists,43
safety initiatives including the Sepsis Six,44 and the increasing
adoption of laparoscopy,45,46 ERPs,12,47 and minimally invasive
management of anastomotic leaks and intra-abdominal collec-
tions. The increasing occurrence of AKI over the 10-year period
likely reflects the use of restrictive fluid regimens as part of
ERPs.48,49 Other hospital factors previously shown to affect
FTR rates include higher nurse to patient ratios, use of high
technology equipment, larger hospital size, intensive care unit
capacity, and teaching status.8,50
Variations in rescue are driven by multiple patient and
hospital macro-system factors, however these only explain a
minority of the observed variations in FTR, suggesting micro-
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Reducing Mortality After Colorectal Surgery
system factors such as hospital culture, communication, and
teamwork likely play a larger role in the recognition, escalation,
and management of deteriorating patients with postoperative
complications.24,51 However, the relative contributions of patient
characteristics, macro- and micro-system factors to improve-
ments in “rescue” are unknown, and these should be further
investigated.
A growing body of work has highlighted inequities in
surgical outcomes for indigenous Māori in Aotearoa New Zea-
land, who consistently have higher postoperative mortality
across a range of surgical procedures, despite risk-adjust-
ment.16,32,52,53 In our data, Māori and patients with low socio-
economic status were over-represented in the highest-mortality
DHBs, even after adjustment in the calculation of O/E mortality
rates. This may reflect outcomes at small hospitals with less
“capacity to rescue” serving populations with high proportions
of Māori patients and patients with high levels of socioeconomic
deprivation. Previous studies from the USA have demonstrated
that FTR contributes to socioeconomic disparities in mortality
following cancer surgery, and this primarily appears to be
mediated by the quality of the hospitals these patients are treated
in.54,55 These perioperative inequities are likely driven by struc-
tural factors stemming from the effects of colonization affecting
access to primary and secondary healthcare. Further inequities
may arise from racism and implicit bias affecting clinician
communication, escalation of care for deteriorating patients, and
provision of ICU-level care or other treatments necessary to
“rescue” patients from complications.32,52,56,57 More work is
needed to identify the specific drivers of these differences
between hospitals treating Indigenous patients, ethnic minorities,
and patients with low socioeconomic status, and consider how
health system resources can best be allocated to ensure equity in
surgical care and “capacity to rescue”.
A strength of this study is the national high-quality data
linkage which allowed for complete 90-day postoperative follow
up across all public hospitals in Aotearoa New Zealand, and
complete capture of all postoperative mortalities (ie, both in and
out of hospital). We used a validated reliability adjustment to
reduce the effect of random error associated with small sample
sizes from some hospitals in this cohort. In addition to overall
FTR, we explored both FTR-Surgical and FTR-NonOp, as
different processes may contribute to variation in these out-
comes. Indeed, much of the improvement in mortality over time
in our cohort was driven by reductions in FTR-NonOp. A
previously-proposed advantage of FTR-S is that it clearly dis-
tinguishes between pre-existing conditions and complications by
using reoperation as the denominator, rather than relying on
coding of complications.5 However, FTR-S captured only 19.6%
of deaths in this cohort. This lower incidence potentially reflects
reduced applicability and statistical power as a quality indicator
if the impact of nonoperative complications is not also
considered.
There are several limitations to this retrospective pop-
ulation-based study of administrative data, including potential
inconsistencies in coding between DHBs or over time. We
included all deaths in the calculation of FTR, as suggested by
Silber et al,58 to minimize any effect of differences in the pro-
portion of deaths without a preceding coded complication
(Appendix 3, Supplemental Digital Content 14, http://links.lww.
com/SLA/E151). A sensitivity analysis accounting for this
assumption showed no difference to the main results when
defining FTR as the rate of death amongst patients having
complications or reoperation (Appendix 3, Supplemental Digital
Content 14, http://links.lww.com/SLA/E151). It is possible that
www.annalsofsurgery.com | 93
 Wells et al
there was not an opportunity to “rescue” some patients, or that
their complications were too severe to “rescue”; however,
determining this was beyond the scope of our study. It was not
possible to identify specific indications for reoperations (eg,
anastomotic leak) or account for the introduction of laparo-
scopic surgery as ICD-10-AM eighth edition laparoscopic-
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specific codes were only introduced in 2014. Despite risk
adjustment, high-mortality DHBs had higher rates of acute
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 10/11/2023
surgery and patients with more advanced disease and higher
levels of socioeconomic deprivation. This may reflect incomplete
risk adjustment; however, hospital-level disparities in outcomes
are clearly apparent, and further work is needed to improve
these. Multiple overlapping perioperative interventions and
advances in surgical approach were introduced during the study
period, and determining their relative impact was not possible.
Finally, we were unable to account for differences in the selec-
tion of patients for surgery.
This study highlights the importance of interventions
aimed at improving rescue, as well as reducing complications
after major colorectal surgery. Substantial regional disparities
exist in Aotearoa New Zealand, with important implications for
the current public health system reform under a national service.
Hospitals and DHBs should consider both structural and cul-
tural factors potentially affecting their “capacity to rescue”
patients from postoperative complications; local audit and
quality improvement should aim to improve the early identi-
fication and escalation of deteriorating patients. Prior studies
have shown that nursing skill and ratios, availability of intensive
care specialists, rapid response teams, communication hier-
archies, and hospital safety culture all affect hospital “capacity
to rescue”.50,59–61 Other factors such as the availability of acute
operating theatres, diagnostic and interventional radiology, and
on-call rostering of senior and junior medical staff may also
affect FTR and should be considered at local and national levels.
Further policy focus on perioperative care and “capacity to
rescue” is essential for achieving equity and enhancing the
quality of surgical care.
There are no citations for SDC tables 5 and 6. Links
given here.
Supplemental Tables 5 and 6, Supplemental Digital
Contents, 15 & 16, http://links.lww.com/SLA/E152 & http://
links.lww.com/SLA/E153
ACKNOWLEDGMENTS
We would like to sincerely thank Sean Carroll from the
New Zealand Ministry of Health National Collections team for
his excellent help with extracting data for this analysis. We would
also like to thank Pieta Brown from Orion Health for her assis-
tance with accessing the NZRISK API calculation. This work was
funded by the Health Research Council of New Zealand (22/45).
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