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Lower emergency general surgery (EGS) mortality among hospitals with higher quality trauma care

Scott, John W. MD, MPH1,2; Tsai, Thomas C. MD, MPH1; Neiman, Pooja U. MD, MPA1; Jurkovich, Gregory J. MD3; Utter, Garth H. MD, MSc3; Haider, Adil H. MD, MPH2,4; Salim, Ali MD2,4; Havens, Joaquim M. MD2,4

Journal of Trauma and Acute Care Surgery: December 14, 2017 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/TA.0000000000001768
AAST 2017 Podium Paper: PDF Only

Background Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to non-modifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Though the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality.

Methods Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with >400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with >200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile.

Results Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21%(inter-quartile range:0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile; as well as patients’ community income-level and race/ethnicity (p<0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95%CI: 0.94-1.25%) at hospitals in the lowest-quartile for risk-adjusted trauma mortality, and 1.64% (95%CI: 1.48-1.80%) at hospitals in the highest-quartile of trauma mortality(p<0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities both found similar trends (p<0.01).

Conclusions Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for emergency general surgery procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. EGS-specific systems- and process-measures are needed to better understand drivers of variation in quality of EGS outcomes.

Level of Evidence Level III, Epidemiological

1Department of Surgery, Brigham and Women’s Hospital, Boston, MA

2Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA

3Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, UC Davis Health System, Sacramento, California

4Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA

Corresponding Author: John W. Scott, MD MPH, 75 Francis Street - CA034, Boston, MA 02115, 617-943-7211.

Meetings: This work was presented as a podium presentation at the 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 13-16, 2017, Baltimore, MD

Relevant Funding: None

© 2018 Lippincott Williams & Wilkins, Inc.