Hospital variation in 'days alive and out of hospital' after colorectal cancer surgery: a national retrospective cohort study.

[BACKGROUND] Postoperative mortality varies between hospitals, largely driven by differences in failure to rescue rather than complication rates. Although failure to rescue focuses on mortality, it does not capture broader patient-centred outcomes. Days alive and out of hospital (DAOH) reflects survival, recovery, and hospital resource use. We hypothesised that hospital-level variation in DAOH within 90 days of surgery (DAOH) would be greater among patients with postoperative complications, reflecting 'capacity to rescue'.

[METHODS] A retrospective cohort study was conducted using linked, population-based national registry data for patients undergoing colorectal cancer resection in Aotearoa New Zealand (2005-2020). Risk-adjusted DAOH values were calculated using direct standardisation, stratified by the occurrence of complications. Hospital-level variation was analysed across percentiles of DAOH, and correlations with mortality and failure to rescue were assessed.

[RESULTS] Among 23 948 patients, 44.5% experienced postoperative complications. DAOH was lower for patients with complications (median, 72 vs 82 days; P<0.001). Hospital variation in DAOH was most pronounced at lower percentiles (25th percentile range, 67-75 days; 10th percentile range, 39-62 days), driven by variation amongst patients with complications. Minimal variation was observed among patients without complications. DAOH correlated strongly with failure to rescue (r=-0.82) and mortality (r=-0.87), supporting its potential as a quality indicator.

[CONCLUSIONS] Hospital variation in DAOH among patients with complications reflects differences in capacity to rescue. DAOH extends the concept of failure to rescue to include nonfatal outcomes, providing a patient-centred quality measure that complements traditional indicators of surgical performance, and could aid in national benchmarking and quality improvement.