Major surgery in Victoria and the United States: a comparison of hospital mortality in older patients.

BACKGROUND: Knowledge is limited on how surgical outcomes compare between different geographical and health organisation settings. OBJECTIVE: To compare demographic features, surgery rates and in-hospital outcomes for 14 major types of surgery in older patients between the state of Victoria in Australia and the United States. METHODS: We obtained US Medicare data and data from the Department of Human Services Victorian Admitted Episodes Database for patients older than 65 years who underwent one of six major cardiovascular procedures or eight major cancer resections in a 5-year period (1994-1999 and 1998- 2003, respectively). Data comprised patient age, sex and elective versus non-elective status, operation type, surgical volume and postoperative hospital mortality. RESULTS: The number of operations performed per capita was 2.6 times greater in the US system than in Victoria. Overall, postoperative hospital mortality was lower in Victoria (3.96% v 4.47%, P < 0.001). It was also lower in Victoria for four major cardiothoracic procedures (coronary artery bypass grafting: 2.79% v 4.63% in the US, P < 0.001; aortic valve replacement, 5.30% v 7.94%, P < 0.001; mitral valve replacement, 6.52% v 13.24%, P < 0.001; pulmonary lobectomy, 2.16% v 4.72%, P = 0.01), but was higher for nephrectomy (3.59% v 2.33%, P = 0.04) and colectomy (7.33% v 4.67%, P < 0.001). The Victorian patients included a smaller proportion of women (35.24% v 41.23%, P < 0.001) and people older than 75 years (39.58% v 44.48%, P < 0.001). US patients were significantly more likely to have their admission status classified as non-elective (45.45% v 34.98% in Victoria, P < 0.001). CONCLUSIONS: Despite limitations on interpretation inherent in comparing outcomes from different jurisdictions, these findings suggest major differences between Victoria and the US in surgical management of patients older than 65 years. Surgical intervention rates appear lower in Victoria, particularly in patients older than 75 years. For patients who receive major cardiothoracic procedures, in-hospital mortality is lower in Victoria than in the US; for colectomy and nephrectomy, it is higher in Victoria; and for other procedures, it is similar.