The public health burden of emergency general surgery in the United States

Gale, Stephen C.; Shafi, Shahid; Dombrovskiy, Viktor Y.; Arumugam, Dena; Crystal, Jessica S.

doi:10.1097/ta.0000000000000362

Cited by 357 publications

(193 citation statements)

References 28 publications

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“…These findings are consistent with other reports suggesting that hospitals with ACS models function as broad safety-net hospitals to both otherwise underserved sociodemographic groups and more severely ill patients (27, 28). This is likely due to the fact that hospitals adopting ACS are more likely to take on that role across many diagnoses (e.g.…”

Section: Discussionsupporting

confidence: 93%

“…Our univariate analysis suggests that appendicitis patients treated at ACS hospitals incurred higher total charges compared to patients treated at GSOC hospitals; however, this difference did not persist in our multivariable analysis adjusting for type of intervention, any complication, age, race, primary insurance, severity of illness, and hospital characteristics.. This finding suggests that the higher costs at safety-net hospitals may be associated with serving a more underserved or severely ill patient population (27). …”

Section: Discussionmentioning

confidence: 71%

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The impact of acute care surgery on appendicitis outcomes

Madore

Collins²,

Aytürk³

et al. 2015

Journal of Trauma and Acute Care Surgery

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Background Acute appendicitis is the most common indication for emergency general surgery (EGS) in the US. We examined the role of acute care surgery (ACS) on interventions and outcomes for acute appendicitis at a national sample of university-affiliated hospitals. Methods We surveyed senior surgeons responsible for EGS coverage at University HealthSystems Consortium (UHC) hospitals, representing >90% of university-affiliated hospitals in the US. The survey elicited data on resources allocated for EGS during 2013. Responses were linked to UHC outcomes data by unique hospital identifiers. Patients treated at hospitals reporting hybrid models for EGS coverage were excluded. Differences in interventions and outcomes between patients with acute appendicitis treated at ACS hospitals vs. hospitals with a general surgeon on-call model (GSOC) were analyzed using univariate comparisons and multivariable logistic regression models adjusted for patient demographics, clinical acuity, and hospital characteristics. Results We found 122 hospitals meeting criteria for analysis where 2,565 patients were treated for acute appendicitis. 48% of hospitals had an ACS model (N =1414), and 52% had a GSOC model (N=1151). Hospitals with ACS models were more likely to treat minority patients with greater severity of illness than GSOC models. Patients treated at ACS hospitals were more likely to undergo laparoscopic appendectomy. In multivariable modeling of patients who had surgery (N=2,258), patients treated at ACS hospitals had 1.86 [95%CI 1.23,2.80] greater odds of undergoing laparoscopic appendectomy. Conclusion In an era when laparoscopic appendectomy is increasingly accepted for treating uncomplicated acute appendicitis, particularly in low risk patients, it is concerning that patients treated at GSOC model hospitals are more likely to undergo traditional open surgery despite having less severity of illness at the time of presentation. Furthermore, hospitals with ACS are functioning as safety net hospitals for vulnerable patients with acute appendicitis. Level of Evidence III

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 71%

The impact of acute care surgery on appendicitis outcomes

Madore

Collins²,

Aytürk³

et al. 2015

Journal of Trauma and Acute Care Surgery

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show abstract

“…(9, 11, 18, 19) Despite the increasing utilization of non-operative management in surgery, clinical outcomes related to non-operative management strategies are rarely evaluated. Diseases such as diverticulitis, SBO, cholecystitis, choledocholithiasis, and even appendicitis are being managed non-operatively at increasingly high rates.…”

Section: Discussionmentioning

confidence: 99%

Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot

Wandling

Bankey

et al. 2017

J Trauma Acute Care Surg

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Background Patients managed non-operatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where non-operative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed non-operatively to evaluate variability in non-operative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered. Methods Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in non-operative patients, rates of adverse outcomes were identified and hospitals were ranked by performance with and then without including non-operative cases. Results 2,091 patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of non-operative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS Pilot, non-operative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of non-operative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with 4 hospitals changing by 3 or more positions. Conclusions This study identifies a gap in performance evaluation when non-operative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating non-operative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include non-operative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation. Level of Evidence III, Prognostic and Epidemiological

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“…More than 3 million patients are admitted annually to US hospitals with EGS conditions, representing over 7% of all US hospitalizations. Moreover, there are over 850,000 EGS operations performed annually in the USA 7, 8…”

Section: The Past – the Birth Of Emergency General Surgerymentioning

confidence: 99%

“…Since 2013, there have been further attempts to define the scope of emergency general surgery. A follow‐up study proposed 149 ICD‐9 procedure codes that could or would treat any of the previously defined 621 ICD‐9 diagnosis codes 8. In 2016, a study querying the National Inpatient Sample defined 7 procedure groups accounting for approximately 80% of the operative EGS burden throughout the USA 12.…”

Section: The Presentmentioning

confidence: 99%

Past, present, and future of Emergency General Surgery in the USA

Lyu

Najjar

Havens

2018

Acute Medicine & Surgery

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Emergency General Surgery (EGS) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS. Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.

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The public health burden of emergency general surgery in the United States

Abstract: Epidemiologic study, level III.

Cited by 357 publications

References 28 publications

The impact of acute care surgery on appendicitis outcomes

The impact of acute care surgery on appendicitis outcomes

Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot

Past, present, and future of Emergency General Surgery in the USA

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