Abdus Sabour Shaik

Background: Failure-to-rescue (FTR), defined as death following postoperative complications, is an established measure of surgical quality to capture a healthcare system’s ability to recognize and intervene in clinical deterioration. Prior studies have demonstrated that surgical mortality variation is driven more by differences in a respective system’s FTR than by the complication rates themselves [1]. Separately, socioeconomic and neighborhood level-deprivation have been associated with worsened outcomes following major oncologic surgery [2]. However, the mechanisms of such disparities remain incompletely understood. This review aims to evaluate the relationship between neighborhood deprivation and FTR, exploring delays in recognition and escalation as a potential mechanistic pathway.

Methods: A structured literature review was conducted using PubMed and Scopus. Search terms included “failure-to-rescue”, “surgical oncology”, “socioeconomic status”, “neighborhood deprivation”, “area deprivation index”, and “escalation of care”. Studies were included if they evaluated postoperative mortality or FTR in relation to socioeconomic or neighborhood-level deprivation factors. Foundational studies defining FTR as well as recent literature examining modern healthcare disparities and system-level contributors were reviewed.

Results: Across literature, patients from socioeconomically disadvantaged backgrounds demonstrated higher postoperative mortality following major oncological procedures [2]. This disparity appears to be driven in part by increased FTR rather than differences in complication incidence [2]. In a large retrospective study, patients in the lowest socioeconomic quintile had significantly higher mortality and FTR rates compared to those in the highest quintile [2]. Mechanistic studies suggest that compounding factors such as delayed recognition of clinical deterioration, impaired communications, and slow escalation of care contribute to FTR, with prior reviews highlighting delayed escalation in a substantial proportion of cases [3]. Recent analyses indicate that treatment at higher-quality hospitals may attenuate socioeconomic disparities in mortality, likely influenced by hospital level factors such as nurse staffing, monitoring systems, and institutional quality [4-6].

Conclusion: Socioeconomic disparities in oncologic surgery outcomes are influenced not only by patient-level factors but also by variation in system-level responsiveness to postoperative complications. This review suggests that delays in recognition and escalation of care may represent a key pathway linking neighborhood deprivation to increased FTR. These findings suggest that disparities in outcomes may be partially modifiable through improvements in perioperative monitoring, escalation protocols, and equitable access to high-quality surgical care. Future research should integrate multi-institutional datasets, including NSQIP, SEER-Medicare, and the National Cancer Database, with neighborhood-level measures such as the Area Deprivation Index to quantify delays in escalation of care and their role in mediating disparities in failure-to-rescue.

Works Cited

1. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009.
2. Reames BN, et al. Socioeconomic disparities in mortality after cancer surgery: failure to rescue. JAMA Surg. 2014.
3. Johnston MJ, et al. Failure to rescue and escalation of care in surgery: a systematic review. Ann Surg. 2015.
4. Friese CR, et al. Hospital characteristics and outcomes in surgical oncology patients.
5. Bonner SN, et al. Neighborhood deprivation, hospital quality, and mortality after cancer surgery. 2023.
6. Lasater KB, McHugh MD, et al. Chronic hospital nurse understaffing is associated with increased mortality. BMJ Quality & Safety. 2021.