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Emergency Surgery for Medicare Beneficiaries Admitted to Critical Access Hospitals

Ibrahim, Andrew M. MD, MSc; Regenbogen, Scott E. MD, MPH; Thumma, Jyothi R. MPH; Dimick, Justin B. MD, MPH

doi: 10.1097/SLA.0000000000002216
Original Articles

Objective: The aim of this study was to compare the surgical outcomes of emergency operations performed at critical access and non-critical access hospitals.

Background: Critical access hospitals are often the only source of surgical care for rural populations. Previous studies have demonstrated that patients undergoing common, elective operations at these rural hospitals have similar outcomes to their urban counterparts. Little is known, however, about the quality of care these hospitals provide for emergency operations for which they are most essential.

Methods: We performed a cross-sectional retrospective review of 219,170 urgent or emergency colon resections among Medicare beneficiaries between 2009 and 2012. We compared mortality, serious complications, reoperation, and readmission rates at critical access and non-critical access hospitals using a multivariable logistic regression to adjust for patient factors (age, sex, race, Elixhauser comorbidities,) indication (cancer, diverticulitis, obstruction, inflammatory bowel disease, bleeding), year of operation, and type of operation.

Results: Operative indications were similar at both critical access and non-critical access hospitals with the most common being cancer (38.5% vs 31.1%) followed by diverticulitis (26.9% vs 28.0%). Compared with patients treated at non-critical access hospitals, patients undergoing surgery at critical access hospitals were less likely to have multiple comorbid diseases (% of patients with 2 or more comorbid conditions, 67.5% vs 75.9%; P < 0.01). After accounting for these differences, patients in critical access hospitals had lower risk-adjusted 30-day mortality rates (14.3% vs 16.2%; P = 0.012) and lower rates of serious complications (11.1% vs 27.2%; P < 0.001). However, critical access hospitals had higher rates of reoperation (2.1% vs 1.4%; P = 0.009) and readmissions (22.3% vs 19.4%; P < 0.001).

Conclusions: For emergency colectomy procedures, Medicare beneficiaries in critical access hospitals experienced lower mortality rates but more frequent reoperation and readmission. These findings suggest that critical access hospitals provide safe, essential emergency surgical care, but may need more resources for postoperative care coordination in these high-risk operations.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Reprints: Andrew M. Ibrahim, MD, MSc, Robert Wood Johnson Clinical Scholar (VA Scholar), Institute for Healthcare Policy & Innovation, University of Michigan, 2800 Plymouth Avenue, Building 10–G016, Ann Arbor, MI 48109 2800. E-mail:

JBD has a financial interest in ArborMetrix, Inc., which had no role in the analysis herein.

The remaining authors have no conflicts of interest to disclose.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.