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Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care
John W Scott1, Thomas C Tsai, Pooja U Neiman
1From the Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., T.C.T., P.U.N.); Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., A.H.H., A.S., J.M.H.); Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, UC Davis Health System, Sacramento, California (G.J.J., G.H.U.); and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., J.M.H.).
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 nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although 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 more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 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% (interquartile 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% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 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 EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes.
Level Of Evidence:
Epidemiological, level III; Care management, level IV.
