Journal of Trauma and Acute Care Surgery:
The public health burden of emergency general surgery in the United States: A 10-year analysis of the Nationwide Inpatient Sample—2001 to 2010
Gale, Stephen C. MD; Shafi, Shahid MD, MPH; Dombrovskiy, Viktor Y. MD, MPH, PhD; Arumugam, Dena MD; Crystal, Jessica S. MD
From the Department of Surgery (S.C.G.), Division of Trauma Services, East Texas Medical Center, Tyler, Texas; Department of Surgery (S.C.G., V.Y.D., D.A., J.S.C.), Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey; and Baylor Institute for Health Care Research and Improvement (S.S.), Dallas, Texas.
Submitted: April 14, 2014, Revised: May 6, 2014, Accepted: May 6, 2014.
This study was presented as a poster at the 27th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 14–18, 2014, in Naples, Florida.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site ( www.jtrauma.com).
Address for reprints: Stephen C. Gale, MD, Department of Surgery, Division of Trauma Services, East Texas Medical Center, 1020 E. Idel St, Tyler, TX 75701; email:
Emergency general surgery (EGS) represents illnesses of very diverse pathology related only by their urgent nature. The growth of acute care surgery has emphasized this public health problem, yet the true “burden of disease” remains unknown. Building on efforts by the American Association for the Surgery of Trauma to standardize an EGS definition, we sought to describe the burden of disease for EGS in the United States. We hypothesize that EGS patients represent a large, diverse, and challenging cohort and that the burden is increasing.
The study population was selected from the Nationwide Inpatient Sample, 2001 to 2010, using the AAST EGS DRG International Classification of Diseases—9th Rev. codes, selecting all EGS patients 18 years or older with urgent/emergent admission status. Rates for operations, mortality, and sepsis were compiled along with hospital type, length of stay, insurance, and demographic data. The χ2 test, the t test, and the Cochran-Armitage trend test were used; p < 0.05 was significant.
From 2001 to 2010, there were 27,668,807 EGS admissions, 7.1% of all hospitalizations. The population-adjusted case rate for 2010 was 1,290 admissions per 100,000 people (95% confidence interval, 1,288.9–1,291.8). The mean age was 58.7 years; most had comorbidities. A total of 7,979,578 patients (28.8%) required surgery. During 10 years, admissions increased by 27.5%; operations, by 32.3%; and sepsis cases, by 15% (p < 0.0001). Mortality and length of stay both decreased (p < 0.0001). Medicaid and uninsured rates increased by a combined 38.1% (p < 0.0001). Nearly 85% were treated in urban hospitals, and nearly 40% were treated in teaching hospitals; both increased over time (p < 0.0001).
The EGS burden of disease is substantial and is increasing. The annual case rate (1,290 of 100,000) is higher than the sum of all new cancer diagnoses (all ages/types): 650 per 100,000 (95% confidence interval, 370.1–371.7), yet the public health implications remain largely unstudied. These data can be used to guide future research into improved access to care, resource allocation, and quality improvement efforts.
LEVEL OF EVIDENCE
Epidemiologic study, level III.
In 2006, the Institute of Medicine described emergency care as being at the “breaking point” in the United States; the demand for emergency care continues to grow, while availability and access decline.1 Most recent data document nearly 130 million emergency department (ED) visits per year, with projections to increase annually.2,3 However, rising health care costs, the declining physician workforce,4 and an alarming surge in ED closures3 threaten access and combine to create a true public health crisis.
Surgeons provide emergency care in two settings: trauma (intentional and unintentional injury) and nontrauma surgical emergencies. Trauma care is well characterized and well studied after four decades of national trauma system development.5 In contrast, the “burden of disease” for nontrauma surgical emergencies is unknown. Further, these illnesses are difficult to group into a single “emergency general surgery” (EGS) entity, for study or for treatment standardization, because of the vastly greater number of hospitals providing EGS care and the anatomic and physiologic diversity of the myriad infectious, obstructive, and hemorrhagic emergencies composing EGS.
Typically, surgical emergencies are treated by whomever surgeon may be “on call”—with call assigned, compulsory, and independent of whether that surgeon is immediately available or has the time, resources, or expertise to deliver appropriate care.6,7 The current system results in delays in care,8 significant practice variation,9 and, at times, suboptimal outcomes.10 Indeed, morbidity and mortality for emergency surgery are much greater than after elective surgery,10,11 and the absence of collective EGS investigation prevents separating the impact of suboptimal care from complex physiology as contributors to poor outcomes. Further, surgeon shortages, increased subspecialization, lifestyle demands, and reimbursement pressures have caused fewer surgeons to elect to provide emergency coverage.4,12–14
While the development of the acute care surgery (ACS) specialist15,16 has helped identify and close some of these gaps in care delivery in certain centers,8,17,18 the true national burden of disease for EGS is unknown. Further, because most of the surgical literature describes elective processes, large-scale analyses of EGS outcomes are lacking19 and reports related to ACS have focused largely on individual diseases8,20,21 or process-of-care improvements.22
However, through the efforts of the American Association for the Surgery of Trauma (AAST) and its affiliated organizations, the scientific and clinical approaches to EGS conditions have evolved. An ACS fellowship-training paradigm was created to prepare “trauma surgeons” for all manner of surgical emergencies, rather than focusing on postinjury care; 14 programs have been approved in the United States to date. Further, the AAST has recently defined emergency general surgery, opening the door to more comprehensive study and greater care standardization.23
As ACS evolves, calls have begun for both EGS “regionalization”24 and the creation of quality assurance programs.25 For the first time, EGS is being seen less as a local issue and more as a public health concern worthy of “organized efforts and informed choices of society.26” In this light, defining the “burden” of disease allows clinicians, institutions, and communities to better assess and adjust resource allocation, devise best practice guidelines and performance improvement measures, and initiate multi-institutional research.25 Similar to the evolution of trauma care three decades ago, surgeons believe that this initiative will lead to improvements in timeliness and quality of care and introduce performance improvement and accountability into this often-overlooked area of surgical illness.25
In the present study, on the basis of the newly developed AAST definition of EGS, we sought to describe the burden of disease for emergent surgical diseases in the United States. We believe that EGS patients represent a very large, diverse, and physiologically challenging cohort and that the burden of disease for EGS is increasing. Our aim was to describe the EGS burden of disease and its evolution in the United States during a 10-year period from 2001 to 2010.
PATIENTS AND METHODS
EGS Definition and Study Population
The Nationwide Inpatient Sample (NIS) from 2001 to 2010 was used for analysis. It is maintained by the Agency for Healthcare Research and Quality and was developed as part of the Healthcare Cost and Utilization Project.27 Sampled from State Inpatient Databases, the NIS is the largest all-payer hospital database in the United States, containing discharge data from more than 1,000 hospitals representing more than 8 million actual hospitalizations. The NIS provides a 20% statistically robust representative cross section of US hospital discharges and the opportunity, using weighted calculations, to derive national estimates representing 40 million hospital discharges annually.
The study population was selected using the following inclusion criteria:
- Eighteen years or older
- Admission type was emergent or urgent or from the ED
- EGS disease as a principal diagnosis
Recently, the AAST compiled an initial list of DRG International Classification of Diseases—9th Rev.—Clinical Modification (ICD-9-CM) codes to represent and define EGS disease.23 In all, 309 ICD-9-CM codes were identified (Supplemental Table 1, http://links.lww.com/TA/A425). We used these codes for Selection Criterion 3. To identify surgical procedures performed during admissions, an exhaustive review of ICD-9-CM procedure codes (00.0–99.99) was undertaken. We identified procedure codes that would or could apply to the EGS-defining ICD-9-CM diagnoses (Supplemental Table 2, http://links.lww.com/TA/A426).
Patients with sepsis as a complication were recognized with these ICD-9-CM diagnosis codes in secondary positions: 038.xx, 112.5, 995.91, 995.92, and 785.52. We also used ICD-9-CM diagnosis codes for secondary diagnoses specifying acute organ dysfunction: 785.5x (shock [nontrauma]), 427.5 (cardiac arrest), 458 (hypotension: 458.0, 458.8, 458.9), 796.3 (nonspecific hypotension), 518.81 (acute respiratory failure), 518.82 (other pulmonary insufficiency), 786.09 (respiratory distress/insufficiency), 799.1 (respiratory arrest), 348.31 (septic encephalopathy), 293.0 (acute delirium), 348.1 (anoxic brain damage), 780.01 (coma), 287.4 (secondary thrombocytopenia), 287.5 (thrombocytopenia, unspecified), 286.6 (defibrination syndrome), 286.9 (unspecified coagulation defects), 570 (acute/subacute necrosis of the liver), 572.2 (hepatic coma), 573.4 (hepatic infarction), and 584.x (acute renal failure).
The study population was further classified into “categories” based on diagnosis type. Eleven categories were used as follows: hepatopancreaticobiliary, colorectal, upper gastrointestinal tract (including the appendix), intestinal obstruction, hernia, general abdominal conditions, soft tissue, vascular, cardiothoracic, resuscitation, and “others” (Supplement 1, http://links.lww.com/TA/A425). Analysis by category included overall admissions, operative rate, mortality, and sepsis data.
For comparison with the EGS burden, we queried available published reports for other common public health concerns. For diabetes mellitus28 and human immunodeficiency virus,29 we used data from the Centers for Disease Control and Prevention. For cancer, we reported data from the American Cancer Society.30 For coronary artery disease, heart failure, and stroke, we obtained data from the American Heart Association.31 These data were expressed as annual incidence per 100,000 persons with confidence intervals (CIs).
Data analysis and statistics were performed with the SAS 9.2 software (SAS Institute, Cary, NC). Difference between two groups was tested with the χ2 analysis for categorical variables and the t test for continuous variables. Linear regression analysis and the Cochran-Armitage trend test were used to evaluate time trends in the examined parameters. A value of p < 0.05 was considered significant.
Burden of Emergent Surgical Disease
During the 10-year study period, there were an estimated 388,358,479 hospital admissions in the United States. Of these, 27,668,807 patients (7.12%) were admitted for EGS diagnoses as defined. From 2001 to 2010, both the actual number of EGS admissions and the proportion of admissions attributed to EGS diagnoses increased steadily. In addition, the proportion of EGS patients requiring surgery during their admission increased from 659,340 (27.7%) in 2001 to 872,332 (28.7%) in 2010 (p < 0.0001).
Figure 1A demonstrates the trend in EGS admissions during the study period. The annual number of EGS admissions increased from 2,380,535 in 2001 to 3,034,878 in 2010 (p < 0.0001). For 2010, this represents a nationwide rate of 1,290.3 (95% CI, 1,288.9–1,291.8) per 100,000 people. Surgical volume and rates (Fig. 1B) also increased annually from 659,340 in 2001 to 872,332 in 2010 (p < 0.0001), translating to a 2010 surgical rate of 370.9 (95% CI, 370.1–371.7) per 100,000 people (annual data in Supplemental Table 3, http://links.lww.com/TA/A427).
Figure 2 compares the single-year population-based rates of EGS admissions and surgery with those of certain other notable public health concerns. The population-based EGS burden was significantly higher than several other common public health problems. The 2010 US rate of new diabetes mellitus diagnoses (all ages/types) was 899.4 (95% CI, 898.2–900.7),28 while the incidence of a new cancer diagnosis (all ages/types) was 650.3 (95% CI, 649.3–651.3).30 EGS admissions were three times higher than all heart failure admissions (470.3 [95% CI, 416.6–418.2])31 and all new strokes (417.4 [95% CI, 416.6–418.2])31 from 2009. EGS admission was more than 60 times greater than new human immunodeficiency virus diagnoses (19.7 [95% CI, 19.5–19.9])29 in 2010.
The demographics of the study population and the incidence of common comorbidities are summarized in Table 1. The mean age was 58.7 years, and 35% of the patients were 70 years or older. More than 50% of the study population had at least one chronic comorbid condition. Hypertension was the most common (43%); 20% of the patients were diabetic.
During the study period, 583,154 EGS patients (2.11%) presented with or developed sepsis; of those, 325,746 (56%) met criteria for severe sepsis. Sepsis rates increased significantly during the study period from 1.90% to 2.19% (p < 0.0001) (Fig. 3). The proportion of septic patients with severe sepsis also increased from 49% to 64% (p < 0.0001).
During the study period, 586,496 EGS patients (2.12%) died during their admission. Despite increasing EGS admissions, hospital mortality steadily declined over time, from 2.73% in 2001 to 1.61% in 2010 (p < 0.0001). This decline occurred despite increasing sepsis rates (Fig. 3).
EGS Diagnosis Groups
Hepatopancreaticobiliary conditions were the most common EGS diseases (26%). This group also had a high operative rate (40%) but a low sepsis rate (2%). Colorectal conditions were the next most common but carried relatively low emergent operative rates (16.5%). Hernia requiring admission had the highest operative rates (73%). Admissions for vascular conditions, while small in number, were complicated (sepsis, 6.5%, and mortality, 13.0%). The resuscitation category was the smallest but had the highest mortality (40.2%) and the highest sepsis rate. Of note, nongastrointestinal conditions (vascular, cardiothoracic, soft tissue, resuscitation, and others) comprised more than 20% of EGS admissions (Table 2).
EGS Insurance Rates and Hospital Data
In 2001, only 7% of the patients were uninsured for their EGS admission, which increased steadily to 10% by 2010 (p < 0.0001). Similarly, rates for Medicaid increased from 9.0% to 12.1% (p < 0.0001). Conversely, private insurance coverage decreased from 34.6% to 29.9% (p < 0.0001), while rates for Medicare decreased from 46.9% to 44.4% (p < 0.0001) during the study period. For the combined 10-year period, 56% of all EGS patients (15,344,148) were covered by public insurance (Medicare/Medicaid).
During the study period, the EGS patients were most commonly (84.5%) and increasingly treated at urban hospitals (p < 0.0001). While nonteaching hospitals cared for most of the EGS patients (60.33%), the proportion of patients treated at teaching hospitals increased from 37.5% to 41.8% during the study period (p < 0.0001). The mean length of stay during the study period decreased from 5.34 days in 2001 to 4.90 days in 2010 (p < 0.0001). While seemingly small, a reduction of 0.44 days in length of stay, multiplied by the 3,034,878 admissions in 2010, may have reduced hospital charges by $2.5 billion to $5.3 billion for that year based on the published range of daily hospital charges: $1,853 per day32 to $3,949 per day33 (Fig. 4).
In the present study, we demonstrate, for the first time, that the burden of EGS conditions, affecting more than 1,290 of 100,000 persons per year, far exceeds that of many common, highly publicized and studied public health problems such as new-onset diabetes mellitus (899 of 1,000,000 persons per year) and newly diagnosed cancers (650 of 1,000,000 persons per year). We also demonstrate that more than 3 million patients are admitted annually to US hospitals emergently or urgently with EGS conditions and that more than a quarter of them require surgery during that admission. These are complex patients, with half older than 60 years, and most have comorbidities. While sepsis rates have remained relatively stable during the study period, we document a 40% reduction in mortality (2.73–1.61%) for EGS conditions from 2001 to 2010. We also document that while emergent admissions and surgeries increased, reimbursement for this care may be declining, as EGS patients are increasingly uninsured or underinsured.
Our data support and extend the findings of Shafi et al.23 from the AAST Acute Care Surgery Committee, who first compiled the ICD-9 codes that define EGS and described the burden of “emergent” admissions for a single year (2009) using the NIS. While that study was limited by its single-year analysis and its focus on emergent admission type, our 10-year examination of the same database also includes “urgent” admissions and allows for a more comprehensive estimate of EGS burden and its public health implications. That EGS admissions are increasing is consistent with nationwide trends of ED use across the country,2,3 and the elderly status of most patients is not surprising. The significant mortality reduction noted during the study period is certainly multifactorial but interestingly is most profound after the first release of the Surviving Sepsis Campaign guidelines in 2004.34
Importantly, these are only index hospitalization data and therefore are likely a significant underestimation of the true burden of disease. Not represented is the additional burden of care for delayed surgical interventions undertaken “semielectively” after an initial period of nonoperative management such as colectomy for diverticular disease, interval appendectomy, delayed cholecystectomy, and others. Also not captured are subsequent surgeries required as a result of the first emergent procedure: colostomy reversal, ventral hernia repair, skin grafting, serial wound debridements, and others. Finally, patients seen in the ED by surgeons, who are not admitted to the hospital but rather are discharged from the ED to be followed as outpatients, are also not included, that is, patients with perirectal abscess, nonincarcerated hernia, and biliary colic.
During the study period, we document a progressive change in payer mix for EGS patients. Health care coverage for the uninsured or the underinsured has been the source of significant political debate and was a major impetus to the Patient Protection and Affordable Care Act signed into law in 2010.35 It is not known how these financial trends will impact the growth of ACS, as EGS is incorporated, but a report by Shafi et al.36 indicates that urban trauma centers will be negatively impacted by the expansion of Medicare-type rolls (a major component of the Patient Protection and Affordable Care Act). While EGS care and trauma care are certainly very different, in that our data demonstrate that most patients with EGS conditions are treated in urban centers, and increasingly in academic centers, Medicaid expansion may have a similar impact on EGS care reimbursement.
Our documentation of an ever-increasing EGS volume, coupled with potential financial pressures, may accelerate an already apparent public health crisis: too few surgeons to meet the need.4 In the United States, the number of surgeons practicing annually has remained unchanged, while the population continues to increase.14 Lynge37 documented a 25.91% decrease in practicing general surgeons per a population of 100,000 from 1981 to 2005, and Williams et al.12 project a 9.2% decrease in general surgeons per capita from 2010 to 2030. Further, increased surgeon specialization,7,38 reduced willingness to participate in an emergency call, early retirement, and declining reimbursement have combined to create a crisis in the delivery of emergency surgical care across the country.4,39 While the fusion of EGS with trauma care to create “acute care surgery” will likely stave off the crisis for some larger centers,15,40 many questions remain regarding ACS implementation in general41 and its ability to improve emergency surgical care in rural and underserved areas specifically. Should EGS regionalization become widespread,24 like trauma care before it, the present study will be critical to predict resource needs and guide allocation, to implement and monitor quality improvement initiatives and to ensure ACS sustainability. Future expansion of this work should include the creation of a standardized EGS classification and scoring system to further clarify the EGS burden and to facilitate outcomes research. Together, this and future studies will emphasize the need to strengthen and expand the ACS training paradigm at both the residency and fellowship levels; our data exposing the enormous burden of EGS make clear the vital role that ACS programs will serve in the future of emergency health care delivery.
The present study has several limitations, the most related to its data source. While the NIS is a large and useful database, it is administrative in nature, containing only limited clinical data, and, as a “sample,” it yields only estimates of admissions rather than actual numbers. Without physiologic data within the NIS, no mortality risk assessments or attempt at severity of disease grading for admissions can be made. Importantly, no data are available for the type of physician or surgeon caring for patients, precluding any assessment of decision making for surgery, delays to source control, or other factors contributing to outcomes. With the NIS, data do not include Veteran’s Administration and other federal facilities, and data reporting for certain elements may vary by state, sources of underestimation of EGS burden. Coding errors or modifications to diagnosis or procedure codes may have occurred, which could yield inaccurate conclusions. For our study aim, these limitations are offset by the large number of patients the NIS contains and the ability to enable trend analysis for long periods. Importantly, the NIS has been benchmarked for quality with other common administrative databases and has been proven accurate for reliable analysis. Its relative ease of analysis and cost-effectiveness also contribute to making the NIS, despite its inherent limitations, ideal for this initial, large-scale burden of disease assessment.
EGS conditions represent a very large and complex patient population that is growing annually. In the present study, we explore, for the first time, the public health implications of this massive disease burden and suggest that a crisis is at hand: a growing need for emergency surgical care at a time of progressively declining surgeon availability. While large, urban centers are best equipped to care for many of these complex patients and may serve as foci for regionalization, the sheer volume of patients requiring treatment for EGS conditions may prove prohibitive. Future efforts, using this and other data, must be directed not only at studying processes of care and quality improvement but also at ensuring adequate organizational planning and proper resource allocation for the growth of ACS programs in an evolving health care environment.
S.C.G., D.A., and S.S. designed this study. S.C.G. and D.A. conducted the literature search. V.Y.D. contributed to data collection. S.C.G. performed data analysis. S.C.G., S.S., V.Y.D., and J.S.C. interpreted the data. S.C.G. wrote the manuscript and, with J.S.C., prepared figures. All authors participated in critical revision. S.C.G. and V.Y.D. had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
We thank Vicente Gracias, MD, for his contribution to early study design.
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Acute care surgery; emergency general surgery; epidemiology; public health
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