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Original Study

Gaps in Emergency General Surgery Coverage in the United States

Ingraham, Angela M. MD, MS*; Chaffee, Scott M. BS†,‡; Ayturk, M. Didem MS§; Heh, Victor K. PhD†,‡; Kiefe, Catarina I. MD, PhD§; Santry, Heena P. MD, MS†,‡

Author Information
doi: 10.1097/AS9.0000000000000043

INTRODUCTION

Emergency general surgery (EGS) care is an under-recognized, yet significant public health burden. EGS conditions afflict more than 12,900 of 1,000,000 persons annually, exceeding that of common, highly publicized, and well-studied public health concerns, such as new-onset diabetes mellitus (899 of 1,000,000 persons annually) and newly diagnosed cancers (650 of 1,000,000 persons annually).1–4 EGS patients constitute 7.2% of total hospitalizations in the United States, with more than a quarter of these patients requiring surgery during their admission.1 The number of EGS patients is growing with a 27% increase over 10 years, from 6.4% in 2001 to 7.8% in 2010.1 Additionally, the total national cost of EGS hospitalizations in 2010, not including physician fees or posthospitalization care, was approximately $28.4 billion. With the increasing number and aging of the US population, this cost is expected to rise to more than $41 billion by 2060. Thus, EGS care ranks as the most expensive cause of unplanned hospitalization in the United States.5

In addition to the burden of disease, EGS patients are at high risk for morbidity and mortality. Approximately half of all patients undergoing EGS will develop a postoperative complication.2 Additionally, between 4% and 14% will be readmitted to the hospital within 30 days of their surgery for a skin/soft-tissue or intrabdominal diagnosis.3 While EGS patients are complex, with half being over the age of 60 and most having comorbidities,1 EGS is an independent predictor of poorer outcomes. In a study using American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data, after controlling for the significantly higher number of comorbid conditions based on ACS-NSQIP preoperative risk assessment, EGS patients were 39% more likely to die within 30 days EGS patients than their counterparts undergoing the same procedures electively.2

While EGS care treats the most acutely ill, highest risk, and most costly general surgery patients,1–4 ensuring their access to that care is a looming public health crisis. The ever-increasing and aging US population is not being matched by graduating general surgeons.6 The number of general surgeons in practice in the United States decreased by 2.3% between 1996 and 2006. Increased subspecialization, lifestyle demands, early retirement, and reimbursement pressures have led to fewer surgeons providing emergency coverage.7–13 Williams et al projected a 9.2% decrease in general surgeons per capita from 2010 to 2030.9 Counties with greater percentages of black, Hispanic, uninsured, and low-education individuals as well as rural counties disproportionately lack access to EGS care.14

In this study, we specifically sought to understand the barriers to round-the-clock EGS care at the hospital level. Thus, the objective of this study was to measure gaps in round-the-clock EGS care in the United States and determine hospital-level predictors of insufficient EGS care.

METHODS

Survey Methodology

We conducted a national survey to determine variations in the delivery of EGS care across all US hospitals where an adult with a general surgery emergency might seek care. Our methods including identification of hospitals providing EGS care, identification of questionnaire respondents (95% surgeons, 4.7% chief medical officers at locations where there was only a single general surgery who did not respond), questionnaire development using an iterative mixed methods process, and our hybrid paper/electronic survey implementation between August and December 2015 conducted in 2 waves have been described elsewhere.15,16 A copy of the questionnaire can be found in Appendix 1, http://links.lww.com/AOSO/A19.

Three questions in the survey focused on round-the-clock EGS care. The first asked “Does your hospital ever lack round-the-clock (24/7/365) emergency general surgery coverage?” This yes/no question included a drop sequence for those responding yes to further answer “Approximately how often does your hospital lack emergency general surgery coverage?” (answered numerically as a percentage) and “How frequent are the following reasons for lacking coverage?” (answered for “Lack of general surgery coverage,” “Lack of anesthesia coverage,” “Lack of OR staff,” “Emergency room is on diversion,” and “Other (please specify) ________” using a Likert scale of Always, Often, Sometimes, Rarely, and Never).

By the end of 2 unique survey implementations, there were 1690 responses from the 2811 eligible acute care hospitals, representing a total response rate of 60.1%. Of these 1634 hospitals responded to our questions specifically regarding round-the-clock EGS coverage, representing 58.1% of the initial 2811 hospitals surveyed. In this manuscript, we present results that are related to the ability of the hospital to provide round-the-clock EGS care. Specific practices related to the structure of EGS teams, ancillary hospital services, and human resources are addressed in other manuscripts.

Statistical Analysis

Questionnaire responses on the availability of round-the-clock EGS care were tabulated and compared by hospital characteristics (geographic region, ownership type, hospital location, teaching status, inpatient bed capacity, medical school affiliation, and trauma certification as reported by the AHA in 2015) using univariate comparisons (χ2). The independent association of any given hospital characteristic with the availability of round-the-clock EGS care was determined using multivariable logistic regression. Hospital characteristics found to have P < 0.20 in univariate comparisons were included in the model. A similar model was constructed for operating room access variables, as reported in the survey (and number of operating rooms as reported in the AHA data), to determine which structures and processes were associated with lack of round-the-clock EGS care. These variables were not included in single model with hospital characteristics due to multicollinearity. Referent categories for structure and process variables were chosen based on prior data regarding which operating room structure and process variables were generally consistent with the acute care surgery model of care designed to provide urgent, round-the-clock access to EGS.17

Maps were generated using Maptitude GIS Mapping Software (Caliper Corp, 2016). All analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). This study was reviewed and deemed exempt by the senior authors’ Institutional Review Board.

RESULTS

Characteristics of hospitals that did and did not respond to our query are detailed in Appendix 2, http://links.lww.com/AOSO/A20.18 Of the 1634 hospitals that responded to our query about round-the-clock EGS care, 279 (17.1%) hospitals lacked round-the-clock EGS care on average 35.7% (SD = 33.6) of the time. Figure 1 depicts the locations across the United States of hospitals that do provide (circles; n = 1355) and do not provide (squares; n = 279) round-the-clock EGS care. Figure 2 depicts distribution of the self-reported percentage of time the latter hospitals lack EGS coverage. A descriptive summary of hospital characteristics comparing those that do and do not provide round-the-clock EGS care is provided in Table 1. Hospitals that do not provide round-the-clock EGS care were more likely to have non-governmental ownership, be located in rural areas, not have teaching affiliations, not be affiliated with a medical school, have smaller bed-sizes, be located in the West North Central region, and not have trauma certification. The table in Appendix 3, http://links.lww.com/AOSO/A21, shows the association of these same characteristics with amount of time EGS coverage was not available.

TABLE 1. - Characteristics Among Acute Care General Hospitals in the United States That Do or Do Not Provide Round-the-Clock Emergency General Surgery Care
Variable Provide Round-the-Clock EGS Care (n = 1355), n (%) Do Not Provide Round-the-Clock EGS Care (n = 279), n (%) p
Ownership <0.0001
 Nongovernmental 990 (73.1) 153 (54.8)
 Governmental   (nonfederal) 217 (16.0) 88 (31.5)
 Investor-owned 148 (10.9) 37 (13.3)
Location <0.0001
 Urban 969 (71.5) 77 (27.6)
 Rural 386 (28.5) 202 (72.4)
Teaching status <0.0001
 Major 158 (11.7) 2 (0.7)
 Minor 568 (41.9) 43 (15.4)
 Nonteaching 629 (46.4) 234 (83.9)
Medical school affiliation <0.0001
 Yes 551 (40.7) 30 (10.8)
 No 804 (59.3) 249 (89.2)
Bed size <0.0001
 <100 393 (29.0) 242 (86.7)
 100–199 347 (25.6) 24 (8.6)
 200–299 215 (15.9) 8 (2.9)
 300–399 146 (10.8) 2 (0.7)
 400 or more beds 254 (18.7) 3 (1.1)
Region <0.0001
 New England 81 (6.0) 9 (3.2)
 East North Central 237 (17.5) 50 (17.9)
 East South Central 92 (6.8) 31 (11.1)
 Middle Atlantic 178 (13.1) 13 (4.7)
 Mountain 99 (7.3) 30 (10.8)
 Pacific 129 (9.5) 12 (4.3)
 South Atlantic 236 (17.4) 29 (10.4)
 West North Central 152 (11.2) 62 (22.2)
 West South Central 151 (11.1) 43 (15.4)
Trauma certification 0.0043
 Yes 675 (49.8) 112 (40.1)
 No 608 (44.9) 149 (53.4)
The sample size was n = 1634. Cell totals may not equal 1634 if the variable was missing or not reported in the American Hospital Association Annual Survey.

FIGURE 1.
FIGURE 1.:
Map of 1,634 US-based, adult acute care general hospitals that have an emergency room and ≥1 operating room that do (circle; n = 1355) and do not (square; n = 279) provide round-the-clock EGS care. EGS indicates emergency general surgery.
FIGURE 2.
FIGURE 2.:
Histogram of estimated percentage of time hospitals that do not provide round-the-clock emergency general surgery care are not able to provide it (n = 279). Percentage of time by self-report ranging from 1 to 99. EGS indicates emergency general surgery.

Among the 279 hospitals that responded that they could not provide round-the-clock EGS care, reasons for being unable to provide such care varied (Table 2). The most common reason for not being able to provide round-the-clock EGS care was a lack of general surgery coverage with 162 (58.1%) of the 279 hospitals citing this as the reason they could not provide round-the-clock EGS care “Always” or “Often” whereas lack of anesthesia coverage (55 [19.7%]), lack of operating room staff (54 [19.4%]), and the emergency room being on diversion (6 [2.1%]) were less often cited.

TABLE 2. - Reasons for Not Providing Round-the-Clock Emergency General Surgery Care at Acute Care General Hospitals in the United States
Response Lack of General Surgery Coverage, n (%) Lack of Anesthesia Coverage, n (%) Lack of Operating Room Staff, n (%) Emergency Room Is on Diversion, n (%)
Always 113 (40.5) 33 (11.8) 32 (11.5) 4 (1.4)
Often 49 (17.6) 22 (7.9) 22 (7.9) 2 (0.7)
Sometimes 52 (18.6) 26 (9.3) 25 (9.0) 27 (9.7)
Rarely 52 (18.6) 51 (18.3) 49 (17.6) 113 (40.5)
Never 11 (3.9) 142 (50.9) 144 (51.6) 126 (45.2)
Missing 2 (0.7) 5 (0.4) 7 (0.5) 7 (2.5)
The sample size was n = 279.

Table 3 compares hospital that did and did not provide round-the-clock EGS care based on survey responses regarding operating room access. Hospitals with fewer operating rooms, less block time, lack of a tiered system for booking emergency cases or a process to defer elective cases, higher frequency of surgeons covering EGS call having competing clinical roles, working postcall, not taking in-house call, not also covering trauma or ICU while on EGS call, and not receiving a stipend for taking EGS call were associated with lack of providing round-the-clock EGS care. Lower rates of in-house or on-call perioperative staff were also associated with lack of providing round-the-clock EGS care.

TABLE 3. - Differences in Structure and Processes as They Relate to Operating Room Access Between Hospitals That Do or Do Not Provide Round-the-Clock EGS Care
Provide Round-the-Clock EGS Care (n = 1355), n (%) Do Not Provide Round-the-Clock EGS Care (n = 279), n (%) p  *
Operating room availability
 Number of operating rooms
  <10 646 (47.7%) 247 (86.4%) <0.0001
  10–20 362 (26.7%) 9 (3.2%)
  >20 247 (18.2%) 4 (1.4%)
  Not available 100 (7.4%) 25 (9.0%)
 Block time for EGS (%)
  <1 block time 1065 (78.6%) 249 (89.3%) <0.0001
  1–4 d 61 (4.5%) 12 (4.3%)
  ≥5 d 187 (13.8%) 5 (1.8%)
  Not available 42 (3.1%) 13 (4.7%)
 Tiered system for booking emergent surgical cases (yes) 912 (67.3%) 110 (39.4%) <0.0001
 Process to defer elective cases (yes) 977 (72.1%) 151 (54.1%) <0.0001
Surgical coverage
 Daytime surgeons covering EGS free of other clinical duties (yes) 169 (12.5%) 6 (2.2%) <0.0001
 Daytime surgeon on call for EGS working postcall
  Always/often 1095 (80.8%) 240 (89.0%) <0.0001
  Sometimes 129 (9.5%) 3 (1.1%)
  Rarely/never 89 (6.6%) 4 (1.4%)
 In-house surgeon overnight for EGS <0.0001
  Always/often 458 (33.8%) 52 (18.6%)
  Sometimes 87 (6.4%) 18 (6.5%)
  Rarely/never 766 (56.5%) 175 (62.7%)
 Overnight surgeon also responsible for covering trauma
  Always/often 859 (63.4%) 137 (49.1%) <0.0001
  Sometimes 78 (5.8%) 22 (7.9%)
  Rarely/never 376 (27.8%) 88 (31.4%)
 Overnight surgeon also responsible for covering ICU care
  Always/often 457 (33.7%) 56 (20.1%) <0.0001
  Sometimes 148 (10.9%) 19 (6.8%)
  Rarely/never 708 (52.3%) 173 (62.0%)
 Overnight surgeon also responsible for covering EGS at more than one hospital
  Always/often 223 (16.5%) 39 (14.0%) <0.0001
  Sometimes 159 (11.7%) 25 (9.0%)
  Rarely/never 929 (68.6%) 181 (64.9%)
 Surgeon covering EGS receives stipend beyond billing for services rendered <0.0001
  Always/often 537 (39.6%) 37 (13.3%)
  Sometimes 93 (6.9%) 17 (6.1%)
  Rarely/never 677 (50.0%) 193 (69.2%)
Overnight perioperative staffing
 Overnight scrub techs
  None 4 (0.3%) 1 (0.4%) <0.0001
  On-call 929 (68.6%) 194 (69.5%)
  In-house 390 (28.8%) 6 (2.2%)
 Overnight OR nurses <0.0001
  None
  On-call 938 (69.2%) 196 (70.3%)
  In-house 390 (28.8) 5 (1.8%)
 Overnight recovery room nurses <0.0001
  None 24 (1.8%) 11 (3.9%)
  On-call 1091 (80.5%) 186 (66.7%)
  In-house 208 (15.4%) 3 (1.1%)
 Overnight anesthesia staff (MD, DO, CRNA)
  None 149 (11.0%) 122 (43.7%) <0.0001
  On-call 732 (54.0%) 57 (20.4%)
  In-house 432 (31.9%) 9 (3.2%)
*Student t test, Wilcox Rank Sum, and χ2 tests of association where appropriate.
EGS indicates emergency general surgery.

Among the 1634 hospitals who responded to our query on whether they do or do not provide round-the-clock EGS care, on multivariable analysis for hospital characteristics, governmentally owned hospitals, hospitals in rural locations, hospitals with <100 beds, as well as hospitals in the East South Central, West North Central, and West South Central regions had higher odds of lacking round-the-clock EGS care as detailed in (Table 4). Finally, in multivariable analysis of structures and processes that facilitate operating room access, only lack of a tiered system for booking emergency cases, no anesthesia availability overnight, and no stipend for EGS call were associated with inability to provide round-the-clock EGS care (Table 5).

TABLE 4. - Predictors of Inability to Provide Round-the-Clock Emergency General Surgery Coverage Among Acute Care General Hospitals in the United States
Variable OR (95% CI)
Ownership
 Nongovernmental Reference
 Governmental (nonfederal) 1.5 (1.0–2.2)
 Investor-owned 1.5 (0.9–2.6)
Location
 Urban Reference
 Rural 1.8 (1.3–2.6)
Teaching status
 Major Reference
 Minor 0.9 (0.2–5.5)
 Nonteaching 1.3 (0.2–8.9)
Medical school affiliation
 Yes Reference
 No 1.0 (0.5–2.0)
Bed size
 400 or more beds Reference
 <100 22.3 (5.1–98.8)
 100–199 3.2 (0.7–14.2)
 200–299 2.3 (0.5–11.0)
 300–399 1.0 (0.2–7.0)
Region
 New England Reference
 East North Central 1.6 (0.7–3.8)
 East South Central 3.4 (1.3–8.9)
 Middle Atlantic 1.7 (0.6–4.6)
 Mountain 2.4 (1.0–6.2)
 Pacific 1.2 (0.4–3.4)
 South Atlantic 1.2 (0.5–3.0)
 West North Central 2.5 (1.0–5.9)
 West South Central 2.7 (1.1–6.9)
Trauma certification
 Yes Reference
 No 1.3 (0.9–1.8)
The sample size was n = 1634.
CI indicates confidence interval; OR, odds ratio.

TABLE 5. - Operating Room Structure and Process Predictors of Inability to Provide Round-the-Clock Emergency General Surgery Coverage Among Acute Care General Hospitals in the United States
OR (95% CI)
Operating room availability
 Number of operating rooms
  <10 1.85 (0.49–6.98)
  10–20 0.66 (0.17–2.61)
  >20 Ref
 Block time for EGS (%)
  <1 block time 2.64 (0.82–8.51)
  1–4 d 4.42 (0.98–19.97)
  >5 d Ref
 Tiered system for booking emergent surgical cases
  Yes Ref
  No 3.37 (1.87–6.07)
 Process to defer elective cases (yes)
  Yes Ref
  No 0.64 (0.35–1.19)
Surgical coverage
 Daytime surgeons covering EGS free of other clinical duties
Yes Ref
No 1.13 (0.36–3.58)
 Daytime surgeon on call for EGS working postcall
  Always/often 0.91 (0.14–5.81)
  Sometimes 0.51 (0.06–4.38)
  Rarely/never Ref
 In-house surgeon overnight for EGS
  Always/often Ref
  Sometimes 1.61 (0.66–3.95)
  Rarely/never 0.83 (0.49–1.39)
 Overnight surgeon also responsible for covering trauma
  Always/often Ref
  Sometimes 2.8 (1.18–6.67)
  Rarely/never 1.22 (0.71–2.11)
 Overnight surgeon also responsible for covering ICU care
  Always/often Ref
  Sometimes 0.62 (0.27–1.46)
  Rarely/never 1.01 (0.60–1.68)
 Overnight surgeon also responsible for covering EGS at more than one hospital
  Always/often Ref
  Sometimes 2.29 (0.98–5.33)
  Rarely/never 1.47 (0.79–2.75)
 Surgeon covering EGS receives stipend beyond billing for services rendered
  Always/often Ref
  Sometimes 1.54 (0.58–4.12)
  Rarely/never 2.84 (1.67–4.87)
Overnight perioperative staffing
 Overnight scrub techs
  None
  On-call 0.64 (0.13–3.11)
  In-house Ref
 Overnight OR nurses
  None
  On-call 2.90 (0.49–17.14)
  In-house Ref
 Overnight recovery room nurses
  None 0.74 (0.10–5.41)
  On-call 0.75 (0.13–4.23)
  In-house Ref
 Overnight anesthesia staff (MD, DO, CRNA)
  None 16.78 (5.65–49.81)
  On-call 1.88 (0.67–5.25)
  In-house Ref
CI indicates confidence intervals; EGS, emergency general surgery; OR, odds ratio.

DISCUSSION

In this novel, survey of hospitals on the details of how EGS care is provided across the United States, we sought to quantify gaps in round-the-clock EGS care and determine hospital-level predictors of insufficient EGS care. We found that significant gaps in access to round-the-clock EGS care exist in the United States. These gaps are often attributable to workforce deficiencies, particularly a lack of general surgeons, and are primarily at small or rural hospitals. We also describe several factors related to operating room access (operating room availability, surgical coverage, and overnight perioperative staffing). Importantly, in addition to surgeon availability, the structure implemented to tier cases by urgency, the availability of anesthesia staff, and the compensation of general surgeons were associated with lack of round-the-clock EGS care. This emphasizes the fact that emergency general surgery care must be guided and supported by public health efforts and policies.

In 2006, the Institute of Medicine described emergency care as being at the “breaking point” in the United States.19 EGS is a crucial component of emergency care. The public health crisis in delivering EGS care is being accelerated by an imbalance between patients in need and providers to meet the demand.20 While availability and access are declining due to a decrease in the physician workforce8 and an increase in emergency department closures,21 the volume of patients with EGS conditions is increasing. The number of Americans with EGS conditions rose from 2.4 million in 2001 to 3.0 million in 2010.1,22,23 The annual incidence of EGS conditions in the United States (1290 cases/100,000) approaches that of acute myocardial infarction (1462/100,000) and cerebrovascular accident (1472/100,000), 2 diseases that warrant comparable access to care for prompt diagnosis and treatment.1,24

As with myocardial infarction and stroke, EGS patients are particularly vulnerable to crises in emergency care as these conditions are associated with high morbidity and mortality and require round-the-clock access to care. Unlike our study, studies of the imbalance between patients’ needs and access to EGS care have previously focused on patient-level factors, such as insurance coverage,25,26 or surgeon-level factors, such as the reasons for the decreased number of general surgeons in the United States.10

A 2010 survey of emergency room directors at 715 hospitals nationally found that 37% reported inadequate EGS coverage.27 In the present survey, largely of surgeons responsible for overseeing EGS coverage, we found that 17% struggled with providing round-the-clock EGS care. There are several possible reasons for this discrepancy. First, our hospital characteristics were different. Hospitals represented in our survey responses were more likely than those in the survey by Rao et al to be nongovernmental in ownership and less likely to be in the South while more likely to be in the Midwest.27 Additionally, surgeons may feel that by having a surgeon listed on the “on-call schedule” that they are providing round-the-clock EGS coverage. However, we recently reported that 11% of surgeons taking EGS call always/often provide EGS care at more than 1 hospital, in essence reducing availability in certain circumstances.28 Unfortunately, when a surgeon is not available, care must either be delayed or the patient must be transferred elsewhere for definitive diagnosis and treatment. One study examining such transfers found that rural residents were often transferred for common procedures, such as inguinal hernia repairs and cholecystectomies, and traveled an average of 67 miles for care.29 Yet, these transfers might be necessary even if a surgeon capable of performing the necessary operation is available, for example, due to need for specialty critical care resources in the case of patients with significant cardiopulmonary comorbidities but otherwise straightforward surgical problem (eg, appendicitis) or need subspecialty nonsurgical care not available locally (eg, ERCP in the case of choledocholithiasis. Importantly, however, at many referral centers, surgeons covering EGS also cover ICU and trauma28; these competing interests may further delay access to care based on acuity and availability of back-up surgeons.

Compared with other medical and surgical subspecialties, such as cardiac, stroke, and trauma care, providers, hospital and healthcare administrators, as well as public health and policy officials lag behind in efforts to improve the care provided to EGS patients. To the best of our knowledge, this is the most comprehensive study of barriers to round-the-clock EGS care nationally. Given the existing imbalance between the needs of EGS patients and the surgical workforce in the United States, a regionalized system drawing upon the lessons learned from stroke,30 neonatal intensive,31 acute coronary syndrome,32 as well as trauma33 care may optimize access and quality for EGS patients. While it is not sustainable for all EGS conditions to be transferred to a higher level of care from patient, provider, or healthcare system vantage points, strategic planning involving thoughtful allocation of limited resources and deliberate transfers of patients to tertiary centers with round-the-clock general surgery capabilities should be considered to ensure adequate access to EGS care nationally.

Limitations

While a 58% response rate is laudable for survey research, especially among physicians,34 42% of hospitals where an adult with an EGS condition might seek care were not represented in our study. Our comparison of responders to nonresponders showed that responders were more likely to represent large, nonprofit hospitals with a teaching affiliation (Appendix 2, http://links.lww.com/AOSO/A20); therefore, our results may be less generalizable to smaller, governmental, or for-profit hospitals without a teaching affiliation. Second, a limitation of any survey is that the information is only as reliable as the individual who is completing the survey. Targeted efforts were made to ensure that the individual completing the survey was the individual most knowledgeable of the care provided to EGS patients at his/her respective institution.

CONCLUSION

We document that significant gaps in round-the-clock EGS care exist in the United States. A substantial reason for the inability of hospitals to provide care is a lack of general surgeons. While the declining general surgery workforce has been a subject of much scrutiny for at least 2 decades,8–11,35 to our knowledge, this is the first comprehensive national assessment of gaps in EGS care from a hospital perspective. Our results serve to inform policy and performance improvement efforts to ensure that all Americans have timely, appropriate access to EGS care.

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