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Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative
Mark R Hemmila1, Pooja U Neiman, Beckie L Hoppe
1From the Department of Surgery (M.R.H., B.L.H., L.G., K.A.K., J.L.J., J.N.M., J.W.S., L.M.N.), University of Michigan Medical School; Center for Healthcare Outcomes and Policy (M.R.H., P.U.N., L.G., J.W.S.), and National Clinical Scholars Program (P.U.N.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (P.U.N.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (A.Y.Y.), Corewell Health, Grand Rapids; Department of Surgery (H.J.L.), Sparrow Health System, Lansing; Department of Surgery (R.J.G.), Trinity Health Ann Arbor, Ann Arbor; and Department of Surgery (E.J.M.), University of Michigan Health-West, Wyoming, Michigan.
Background:
Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements.
Methods:
We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits.
Results:
Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals.
Conclusion:
A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes.
Level Of Evidence:
Therapeutic/Care Management; Level III.
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