Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions

• Published in: JAMA surgery Vol. 155; no. 3; pp. 216 - 223
• Main Authors: Lee, Katherine C, Sturgeon, Daniel, Lipsitz, Stuart, Weissman, Joel S, Mitchell, Susan, Cooper, Zara
• Format: Journal Article
• Language: English
• Published: United States American Medical Association 01.03.2020
• Subjects: Acute Disease; Aged; Aged, 80 and over; Cohort Studies; Emergency Treatment; Female; Heart Failure - mortality; Heart Failure - surgery; Humans; Male; Medicare; Myocardial Infarction - mortality; Myocardial Infarction - surgery; Online First; Original Investigation; Patient Acceptance of Health Care - statistics & numerical data; Pneumonia - mortality; Pneumonia - surgery; Retrospective Studies; Surgical Procedures, Operative; Treatment Outcome; United States; United States
• ISSN: 2168-6254; 2168-6262
• DOI: 10.1001/jamasurg.2019.5087

IMPORTANCE: Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. OBJECTIVE: To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. DESIGN, SETTING, AND PARTICIPANTS: This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. EXPOSURES: Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. MAIN OUTCOMES AND MEASURES: One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. RESULTS: A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). CONCLUSIONS AND RELEVANCE: In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.