Confounding by indication is a critical challenge in evaluating the effectiveness of surgical interventions using observational data. The threat from confounding is compounded when using medical claims data due to the inability to measure risk severity. If there are unobserved differences in risk severity across patients, treatment effect estimates based on methods such a multivariate regression may be biased in an unknown direction. A research design based on instrumental variables offers one possibility for reducing bias from unobserved confounding compared to risk adjustment with observed confounders. This study investigates whether a physician’s preference for operative care is a valid instrumental variable for studying the effect of emergency surgery. We review the plausibility of the necessary causal assumptions in an investigation of the effect of emergency general surgery (EGS) on inpatient mortality among adults using medical claims data from Florida, Pennsylvania, and New York in 2012–2013. In a departure from the extant literature, we use the framework of stochastic monotonicity which is more plausible in the context of a preference-based instrument. We compare estimates from an instrumental variables design to estimates from a design based on matching that assumes all confounders are observed. Estimates from matching show lower mortality rates for patients that undergo EGS compared to estimates based in the instrumental variables framework. Results vary substantially by condition type. We also present sensitivity analyses as well as bounds for the population level average treatment effect. We conclude with a discussion of the interpretation of estimates from both approaches.

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