Why Potentially Elective General Surgery Becomes Emergent: A Multi-Methods Approach

Emergency general surgery (EGS) has disproportionate morbidity and mortality relative to elective surgery. With earlier intervention, many emergent conditions could be treated electively. Social determinants of health (SDoH) negatively impact access to healthcare, leading to increased utilization of EGS. The goal of this study is to determine why patients with potentially elective disease receive EGS.

Adults undergoing EGS with elective alternatives were identified during 2018-2019 at a single academic center. Patient demographics, clinical course, and circumstances of surgical timing were abstracted from the medical record. We compared factors influencing referral or evaluation by surgeon with chi-square and Mann-Whitney U tests where appropriate. Concurrent, multi-methods were used to determine why patients fail to receive elective surgery.

We identified 995 patients undergoing EGS with an elective alternative. Although 70% had insurance and a primary care physician, only 104 were evaluated by primary care, with 59 referred to and 46 evaluated by general surgery, and 22 ultimately scheduled for elective surgery. Reasons for failure of elective management included comorbidity optimization (42%), difficulties scheduling (28%), SDoH (22%), missed diagnosis (14%), and patient preference (11%). Patients cited difficulties with money, childcare, transportation, and employment within SDoH category. No significant differences in patient demographics were found for patients with and without preoperative outpatient care.

At our institution, most patients are never seen by a physician prior to their admission for EGS. Even with primary care evaluation, individuals still have only a 20% chance of being scheduled for elective surgery. Future efforts must focus on increasing preventive care access within the community and streamlining the process from diagnosis to elective general surgery.