Clinical Consequences Associated With Bypassing Local Surgical Care for Urgent and Emergent Surgery
Mustafa Abid1, Tyler Malone2, Mark Holmes2
1Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Insights
Rural patients bypassing local surgical care for urgent general surgery face higher risks of intensive care unit (ICU) admission and prolonged length of stay (LOS). These outcomes are sensitive to how bypass is defined, impacting rural surgical care accessibility.
Area of Science:
- Health Services Research
- Rural Health
- General Surgery
Background:
- Bypass rates for local surgical care are high among rural populations.
- The clinical impact of bypassing local care for urgent/emergent general surgical conditions in rural patients remains unclear.
Purpose of the Study:
- To investigate the association between bypassing local surgical care and clinical outcomes for rural patients with urgent/emergent general surgical diseases.
- To determine if bypassing nearest surgical hospitals (NSHs) affects mortality, complications, ICU admission, or prolonged length of stay (LOS).
Main Methods:
- Retrospective cohort study using North Carolina inpatient discharge data (2016-2019).
- Bypass defined as seeking care at a hospital other than the NSH, with a minimum 10-mile distance difference.
- Multivariable logistic regression analyzed associations with mortality, complications, ICU admission, and prolonged LOS; sensitivity analysis used alternate bypass definitions.
Main Results:
- 26.6% of rural patients bypassed their NSH for urgent/emergent general surgery, traveling a median of 32.5 miles.
- Bypass was not significantly associated with increased odds of mortality or complications.
- Bypass was significantly associated with increased odds of ICU admission (aOR 1.31) and prolonged LOS (aOR 1.37).
Conclusions:
- Rural patients bypassing local surgical care experience higher risks of ICU admission and prolonged LOS.
- The influence of bypass on clinical outcomes, including mortality and complications, is dependent on the definition of bypass used.
Introduction:
Although bypass rates of local surgical care are high for rural patients, the clinical implications of bypass for urgent/emergent general surgical diseases are unknown for rural patients.
Materials And Methods:
Retrospective cohort study of hospital discharges for urgent and emergent general surgical procedures in the North Carolina inpatient discharge dataset from 2016 to 2019. Bypass was defined as seeking care at a hospital other than a patient's 'nearest surgical hospital' (NSH). NSHs were defined as those (1) nearest to the patient's ZIP Code Tabulation Area centroid, (2) where standard general surgeries were performed in the same fiscal year, and (3) met a threshold of ≥10 miles difference-in-distance between the patient ZIP Code Tabulation Area centroid and NSH compared to the treating hospital. The associations between bypass and mortality risk, complications, intensive care unit (ICU) admission, or prolonged length of stay (LOS) > 75th percentile were estimated using multivariable logistic regression. A sensitivity analysis of alternate bypass definitions was performed.
Results:
Defining bypass at the 10-mile difference-in-distance threshold, 26.6% (n = 2944) bypassed local surgical care. These patients had a median age of 58.0 years (interquartile range [IQR] 43.0-69.0), a median Elixhauser comorbidity score of 2.0 (IQR 1.0-4.0), and drove a median of 32.5 miles for care (IQR 26.2-48.3) compared to a median travel distance of 6.5 miles (IQR 4.0-14.0) for patients who did not bypass local care. Bypass was not significantly associated with odds of mortality (adjusted odds ratio [aOR] 1.34, 95% confidence interval [CI] 0.94,1.91) or complications (aOR 1.18, 95% CI 0.99,1.42). Bypass was significantly associated with increased odds of ICU admission (aOR 1.31, 95% CI 1.00,1.73) and prolonged LOS (aOR 1.37, 95% CI 1.16,1.61). The associations between bypass, mortality, and complications were sensitive to bypass definitions, with greater difference-in-distance thresholds demonstrating a significant association with both mortality and complications.
Conclusions:
Rural patients bypassing local surgery have an increased ICU admission risk and prolonged LOS. The bypass effect on clinical outcomes is sensitive to bypass definitions.
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