Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

Santry, Heena P.; Kao, Lillian S.; Shafi, Shahid; Lottenberg, Lawrence; Crandall, Marie

doi:10.1136/tsaco-2019-000319

Cited by 18 publications

(16 citation statements)

References 91 publications

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“…Some countries have implemented the centralization of complex surgeries in selected hospitals in an attempt to group together the technical skills needed to improve the quality of care [ 5 , 6 , 22 ]. This idea seems attractive, especially if we want to be able to measure hospital performance reliably.…”

Section: Discussionmentioning

confidence: 99%

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Detecting Hospital Outliers in Post‐Pancreatectomy Care Using Funnel Plots from 2009–2018 Based on Nationwide Medico‐Administrative Data

et al. 2021

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Objectives Our objective was to identify hospitals with unusual mortality rates for major pancreatectomies over a period of ten years using 30-day mortality data from the French national database. Methods Data for all patients who underwent pancreatectomy were extracted from the national medico-economic database (Programme de Médicalisation des Systèmes d'Information). To identify quality outliers for each hospital, the observed-to-expected 30-day mortality rates were used as a quality indicator. Results A total of 19 494 patients underwent a major pancreatectomy in France between January 2009 and December 2018. The overall 30-day mortality rate was 4.8% (n = 944). For the 2009–2014 period, the funnel plot showed that 10 of the 176 hospitals lie outside the central 95% region and 7 lie outside the central 99.8% region. For the 2015–2018 period, out of 176 hospitals, 6 lie outside the central 95% region and 2 lie outside the central 99.8% region. The change in standardized mortality ratios between 2009–2014 and 2015–2018 testing for differences from the overall change, they were there 4 hospitals lie outside the central 95% region and 0 lie outside the central 99.8% region. Conclusion Over time, the improvement in hospital quality was weak. This study suggests that there is a pressing need to reorganize the supply of care for pancreatic surgery in France.

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Section: Discussionmentioning

confidence: 99%

“…Compared with other countries, France offers dispersed care for major interventions such as pancreatic surgery, and most private and public hospitals will perform a pancreatic resection at least once a year. This practice could be one of the reasons that the death rate is higher in France than in other countries [ 3 , 4 , 6 , 22 ].…”

Section: Discussionmentioning

confidence: 99%

Detecting Hospital Outliers in Post‐Pancreatectomy Care Using Funnel Plots from 2009–2018 Based on Nationwide Medico‐Administrative Data

et al. 2021

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“…1,2 There are arguments both in favor of and in opposition to the regionalization of EGS care in the United States. 3 Proponents of regionalization argue that this model provides critical access to EGS care for communities who lack surgical coverage or the resources to care for the critically ill and that high-volume centers have shown better outcomes. Opponents argue that regionalization burdens patients and their families and places a strain on urban hospital systems, without providing a clear clinical benefit.…”

Section: Introductionmentioning

confidence: 99%

An evaluation of emergency general surgery transfers and a call for standardization of practices

Bruenderman

Block

Kehdy

et al. 2021

Surgery

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Background There is an increasing trend toward regionalization of emergency general surgery, which burdens patients. The absence of a standardized, emergency general surgery transfer algorithm creates the potential for unnecessary transfers. The aim of this study was to evaluate clinical reasoning prompting emergency general surgery transfers and to initiate a discussion for optimal emergency general surgery use. Methods Consecutive emergency general surgery transfers (December 2018 to May 2019) to 2 tertiary centers were prospectively enrolled in an institutional review board–approved protocol. Clinical reasoning prompting transfer was obtained prospectively from the accepting/consulting surgeon. Patient outcomes were used to create an algorithm for emergency general surgery transfer. Results Two hundred emergency general surgery transfers (49% admissions, 51% consults) occurred with a median age of 59 (18 to 100) and body mass index of 30 (15 to 75). Insurance status was 25% private, 45% Medicare, 21% Medicaid, and 9% uninsured. Weekend transfers (Friday to Sunday) occurred in 45%, and 57% occurred overnight (6:00 pm to 6:00 am). Surgeon-to-surgeon communication occurred with 22% of admissions. Pretransfer notification occurred with 10% of consults. Common transfer reasons included no surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). A minority (36%) underwent surgery within 24 hours; 54% did not require surgery during the admission. Median length of stay was 6 (1 to 44) days. Conclusion Conditions prompting emergency general surgery transfers are heterogeneous in this rural state review. There remains an unmet need to standardize emergency general surgery transfer criteria, incorporating patient and hospital factors and surgeon availability. Well-defined requirements for communication with the accepting surgeon may prevent unnecessary transfers and maximize resource allocation.

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“…More than 3 million admissions of patients with emergency general surgery (EGS) conditions occur annually in the US, accounting for 7.1% of all hospitalizations nationally. 1,2 Emergency general surgury conditions are also associated with high mortality and costs, placing substantial burden on the health care system. 1,[3][4][5][6][7][8][9][10][11] Interhospital transfers of patients with EGS conditions are common, occurring in up to 13% of all EGS encounters, but little is known about the transfer patterns within the network.…”

Section: Introductionmentioning

confidence: 99%

“…1,2 Emergency general surgury conditions are also associated with high mortality and costs, placing substantial burden on the health care system. 1,[3][4][5][6][7][8][9][10][11] Interhospital transfers of patients with EGS conditions are common, occurring in up to 13% of all EGS encounters, but little is known about the transfer patterns within the network. 1,12 Acute care hospitals with EGS services are not evenly distributed with regard to population density or need for care and, at present, there are no standardized guidelines in place to direct patients to those hospitals.…”

Section: Introductionmentioning

confidence: 99%

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

et al. 2021

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IMPORTANCE Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. OBJECTIVE To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021.EXPOSURES Hospital-level measures of size (total bed capacity), resources (intensive care unit[ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (riskadjusted failure to rescue and in-hospital mortality). MAIN OUTCOMES AND MEASURESThe main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. RESULTS Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg,

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Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

Cited by 18 publications

References 91 publications

Detecting Hospital Outliers in Post‐Pancreatectomy Care Using Funnel Plots from 2009–2018 Based on Nationwide Medico‐Administrative Data

Detecting Hospital Outliers in Post‐Pancreatectomy Care Using Funnel Plots from 2009–2018 Based on Nationwide Medico‐Administrative Data

An evaluation of emergency general surgery transfers and a call for standardization of practices

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

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