Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample

• Published in: Trauma surgery & acute care open Vol. 9; no. 1; p. e001288
• Main Authors: Ho, Vanessa P, Towe, Christopher W, Bensken, Wyatt P, Pfoh, Elizabeth, Dalton, Jarrod, Connors, Alfred F, Claridge, Jeffrey A, Perzynski, Adam T
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd 01.06.2024; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Codes; Decision making; Disease; Emergency Treatment; Frailty; general surgery; geriatrics; Hernias; Hospitals; Mortality; Older people; Original Research; Patients; Population; Surgery; Trauma; Trauma care; Ulcers; Variables; United States > US
• ISSN: 2397-5776; 2397-5776
• DOI: 10.1136/tsaco-2023-001288

BackgroundThe decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.MethodsWe included adults aged 65+ years with an EGS condition from the 2016–2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.ResultsOf 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).ConclusionsNearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.Level of evidenceIII.