Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model

Eugene, Natalie; Oliver, Charles M.; Bassett, Mike G.; Poulton, Thomas; Kuryba, Angela; Johnston, Carolyn; Anderson, I. D.; Moonesinghe, Ramani; Grocott, Michael P.W.; Murray, Dave; Cromwell, David; Walker, Kate; Cripps, M. Christine; Cripps, Paul J; Davies, Emma; Drake, Sharon; Galsworthy, Michael J.; Goodwin, James; Salih, Tom; Lourtie, Jose; Papadimitriou, Dimitri; Peden, Carol J.

doi:10.1016/j.bja.2018.06.026

Cited by 119 publications

(147 citation statements)

References 30 publications

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“…The association between deprivation and risk-adjusted 30-day mortality was performed using mixed effects logistic regression of IMD quintile and case-mix variables on 30-day mortality, with a random intercept for hospitals (Objective 3). The selection of case-mix co-variates was based on the previously published NELA risk-adjustment model, 24 which was developed and internally validated from a subset of the data set used in the current study, with continuous patient-level physiological and biochemical parameters transformed where necessary. Additional variables were added to the model to attempt to reduce bias pertinent to this analysis ( Supplementary Table S1).…”

Section: Discussionmentioning

confidence: 99%

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study

Poulton

Moonesinghe

Raine

et al. 2020

British Journal of Anaesthesia

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Background: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. Methods: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Results: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and leastdeprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76e0.92]; Q3: 0.84 [0.76e0.92]; Q4: 0.87 [0.79e0.96]; Q5 [least deprived]: 0.77 [0.70e0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. Conclusions: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

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Section: Discussionmentioning

confidence: 99%

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study

Poulton

Moonesinghe

Raine

et al. 2020

British Journal of Anaesthesia

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“…These analyses are distinct from the development of the NELA risk adjustment model. 42 Multilevel modelling was performed in three steps 30 : a 'hospital-only' variance component model first quantified the magnitude of between-hospital variation in the study endpoints; secondly, addition of the patient-level risk factors (fixed effects) identified previously generated the multilevel model; and thirdly, organisational factors (Table 1) were modelled as blocks of variables. Model output was reported as odds ratios and median odds ratios (MORs), where larger MOR values indicate greater between-hospital variation.…”

Section: Statistical Analysis and Modellingmentioning

confidence: 99%

Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

Oliver

Bassett

Poulton

et al. 2018

British Journal of Anaesthesia

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Background: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. Methods: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30-and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. Results: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76e0.96; and OR: 0.89; 95% CI: 0.81e0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80e0.99; and OR: 0.89; 95% CI: 0.81e0.98) were associated with reduced 30-and 90-day mortality, respectively. In contrast, infrequent consultant-delivered Quality and Patient Safety intraoperative care was associated with increased 30-and 90-day mortality (OR: 1.61; 95% CI: 1.01e2.56; and OR: 1.61; 95% CI: 1.08e2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (!70 yr) patients (OR: 0.35; 95% CI: 0.29e0.42; and OR: 0.64; 95% CI: 0.55e0.73, respectively). Conclusions: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.

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“…This tool has been validated in this group of patients and is the recommended risk calculator for patients undergoing laparotomy. 15…”

Section: Management Of Fluids and Haemodynamic Supportmentioning

confidence: 99%

Management of the patient presenting for emergency laparotomy

2019

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Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model

Abstract: The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.

Cited by 119 publications

References 30 publications

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study

Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

Management of the patient presenting for emergency laparotomy

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