Dataset Information

Hospital Volume and Operative Mortality for General Surgery Operations Performed Emergently in Adults.

ABSTRACT:

Objective

This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk?

Background

Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies.

Methods

Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality.

Results

A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair.

Conclusions

Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.

SUBMITTER: Becher RD

PROVIDER: S-EPMC6803029 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundWithin the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes can require a structured system of surgical care based on key quality indicators. To investigate this, the current study sought to answer 2 questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume will geriatric patients undergoing an emergency operation achieve at or better than average mortality risk?Study designRetrospective cohort study of geriatric patients (aged 65 years and older) who underwent 1 of 10 EGS operations identified from the California State Inpatient Database (2010 to 2011). β-Logistic generalized linear regression was used, with the hospital as the unit of analysis, to investigate the relationship between hospital operative volume and in-hospital riskv-adjusted mortality. Hospital operative volume thresholds to optimize probability of survival were defined.ResultsThere were 41,860 operations evaluated at 299 hospitals. For each operation, mortality decreased as hospital emergency operative volume increased (p < 0.001 for each operation); for every standardized increase in volume (meaning +1 natural logarithm of volume), the reduction in mortality ranged from 14% for colectomy to 61% for appendectomy. Hospital volume thresholds, which optimize to 95% probability of survival, varied by procedure, with a mean of 14 operations over 2 years. More than 50% of hospitals did not meet the threshold benchmarks, representing 22% of patients.ConclusionsSurvival rates for geriatric patients were improved substantially when emergency operations were performed at hospitals with higher operative volumes. Consistent with all active Quality Programs of the American College of Surgeons, hospital operative volume appears to be an important metric of surgical quality for older patients undergoing emergency operations.

Project description:There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected.We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix.Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures.Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.).

Project description:?OBJECTIVES: Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study examined this relationship at the national level. ?DESIGN: This is a national population-based study using a full administrative inpatient dataset (National Quality Assurance Improvement System) from publicly funded hospitals in Ireland. ?SETTING: 24 public hospitals providing EAS services. ?PARTICIPANTS AND INTERVENTIONS: Patients undergoing EAS as identified by primary procedure codes during the period 2014-2018. ?MAIN OUTCOME MEASURES: The main outcome measure was adjusted in-hospital mortality following EAS in publicly funded Irish hospitals. Mortality rates were adjusted for sex, age, admission source, Charlson Comorbidity Index, procedure complexity, organ system and primary diagnosis. Differences in overall, 7-day and 30-day in-hospital mortality for hospitals with low (<250), medium (250-449) and high (450+) volume and surgical teams with low (<30), medium (30-59) and high (60+) volume during the study period were also estimated. ?RESULTS: The study included 10?344 EAS episodes. 798 in-hospital deaths occurred, giving an overall in-hospital mortality rate of 77 per 1000 episodes. There was no statistically significant difference in adjusted mortality rate between low and high volume hospitals. Low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1000 episodes) compared with high volume teams (54.7 deaths/1000 episodes), a difference that persisted among low volume surgeons practising in high volume hospitals. ?CONCLUSION: Patients undergoing EAS managed by high volume surgeons have better survival outcomes. These findings contribute to the ongoing discussion regarding configuration of emergency surgery services and emphasise the need for effective clinical governance regarding observed variation in outcomes within and between institutions.

Project description:ObjectiveTo define geographic variations in emergency general surgery (EGS) care, we sought to determine how much variability exists in the rates of EGS operations and subsequent mortality in the Northeastern and Southeastern United States (US).Summary background dataWhile some geographic variations in healthcare are normal, unwarranted variations raise questions about the quality, appropriateness, and cost-effectiveness of care in different areas.MethodsPatients ≥18 years who underwent 1 of 10 common EGS operations were identified using the State Inpatient Databases (2011-2012) for 6 states, representing Northeastern (New York) and Southeastern (Florida, Georgia, Kentucky, North Carolina, Mississippi) US. Geographic unit of analysis was the hospital service area (HSA). Age-standardized rates of operations and in-hospital mortality were calculated and mapped. Differences in rates across geographic areas were compared using the Kruskal-Wallis test, and variance quantified using linear random-effects models. Variation profiles were tabulated via standardized rates of utilization and mortality to compare geographically heterogenous areas.Results227,109 EGS operations were geospatially analyzed across the 6 states. Age-standardized EGS operation rates varied significantly by region (Northeast rate of 22.7 EGS operations per 10,000 in population versus Southeast 21.9; P < 0.001), state (ranging from 9.9 to 29.1; P < 0.001), and HSA (1.9-56.7; P < 0.001). The geographic variability in age-standardized EGS mortality rates was also significant at the region level (Northeast mortality rate 7.2 per 1000 operations vs Southeast 7.4; P < 0.001), state-level (ranging from 5.9 to 9.0 deaths per 1000 EGS operations; P < 0.001), and HSA-level (0.0-77.3; P < 0.001). Maps and variation profiles visually exhibited widespread and substantial differences in EGS use and morality.ConclusionsWide geographic variations exist across 6 Northeastern and Southeastern US states in the rates of EGS operations and subsequent mortality. More detailed geographic analyses are needed to determine the basis of these variations and how they can be minimized.

Project description:IntroductionDue to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS.MethodsThe 2010-2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences.ResultsOf 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54-0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types.ConclusionThe incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.

Project description:ImportanceFrailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.ObjectiveTo determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.Design, setting, and participantsA retrospective cohort study was conducted of 140?828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.Main outcomes and measuresThe association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.ResultsA total of 140?828 patients (80?147 women and 60?681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n?=?71?455), breast (n?=?51?267), thyroid, or parathyroid surgery (n?=?18?106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P?<?.001) for any complication and 2.00 (95% CI, 1.72-2.34; P?<?.001) for serious complications. A high modified frailty index score (?0.36, corresponding to ?4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P?<?.001) for any complication and 3.95 (95% CI, 2.65-5.87; P?<?.001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P?<?.001).Conclusions and relevanceFrailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.

Project description:IntroductionChronic kidney disease is frequently encountered in clinical practice and often requires more intricate management strategies. However, its impact on outcomes of patients warranting emergency general surgery has not been well characterized. The present study examined the association of chronic kidney disease stage on in-hospital outcomes and readmission following emergency general surgery using a nationally representative cohort.MethodsThe 2016-2018 Nationwide Readmissions Database was queried to identify all adult hospitalizations for 1 of 6 common emergency general surgery operations. Patients were stratified by severity of chronic kidney disease into stages 1-3, stages 4-5, end-stage renal disease, and others (non-chronic kidney disease). Regression models were used to examine factors associated with mortality, readmissions, and costs.ResultsOf an estimated 985,101 patients undergoing emergency general surgery, 60,949 (6.2%) had a diagnosis of chronic kidney disease (1-3: 67.1%, 4-5: 11.5%, end-stage renal disease: 23.4%). Unadjusted rates of mortality increased with chronic kidney disease in a stepwise manner (2.1% in non-chronic kidney disease to 16.9 in end-stage renal disease, P < .001), as did 90-day readmissions (9.2% to 29.7%, respectively, P < .001). After adjustment, all stages of chronic kidney disease exhibited increases in risk-adjusted rates of mortality (range: 0.2% in chronic kidney disease 1-3 to 12.2% in end-stage renal disease, P < .001). Relative to non-chronic kidney disease, end-stage renal disease had the greatest cost burden for those undergoing small bowel resection (β +$83,600) and the least in cholecystectomy (+$30,400).ConclusionChronic kidney disease severity is associated with a stepwise increase in mortality, hospitalization costs, and 90-day readmissions. Our findings may better inform shared decision-making and have implications in benchmarking. Further studies for optimal management strategies in this high-risk group are needed.