Operative Decision Discordance in Geriatric Emergency General Surgery

Nearly 1 million older adults are hospitalized annually for emergency general surgery (EGS) conditions in the United States. Recent literature has demonstrated the impact of discordant care in EGS, defined as a mismatch between treatment choice and patients' clinical risk profile. In the present work, we characterize the association between preoperative decision variation and outcomes in elderly EGS patients.MethodsAll geriatric (≥65 years) hospitalizations with EGS conditions (appendicitis, diverticulitis, cholecystitis, hernia, bowel obstruction, perforated peptic ulcer, intestinal ischemia, perforated bowel) were tabulated from the 2022 National Inpatient Sample (NIS). A propensity score (PS) was developed to estimate the likelihood of undergoing operative management. Low and high probability for surgery was defined using a cut-off of PS = 0.5. Model-concordant cases were defined as those whose treatment matched their predicted likelihood, while model-discordant cases did not. Multivariable regression models were developed to determine the association of care variation on outcomes.ResultsOf an estimated 900 730 patients with EGS conditions, 154 300 (17.1%) were classified as model-discordant. Following risk adjustment, model-discordance was associated with greater odds of mortality (AOR: 1.33, 95% CI: 1.25-1.42), as well as gastrointestinal (AOR: 2.07, 95% CI: 1.95-2.19), infectious (AOR: 1.41, 95% CI: 1.36-1.46), and respiratory (AOR: 1.26, 95% CI: 1.20-1.32) complications. Furthermore, model-discordance was associated with increased hospitalization costs (β: +$9 760, 95% CI: +$9 255-10 265) and length of stay duration (β: +2.72 days, 95% CI: +2.59-2.84).ConclusionPatients classified as model-discordant exhibited elevated rates of in-hospital mortality and postoperative complications. Given this variation, our study warrants investigation into guideline adherence and outcomes in this vulnerable population.