Seven Emergency Surgeries Tied to Most Deaths, Complications

Troy Brown, RN

April 27, 2016

Seven types of emergency general surgeries (EGSs) account for the vast majority of all EGSs (80.0%), deaths (80.3%), complications (78.9%), and inpatient costs (80.2%), according to a retrospective review of 421,476 procedures performed in the United States.

The surgical procedures include partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy.

"This is a particularly high-risk population of surgery patients — those who undergo an EGS operation are up to 8 times more likely to die postoperatively than are patients undergoing the same procedures electively. In addition, approximately half of all patients undergoing EGS will develop a postoperative complication, and up to 15% will be readmitted to the hospital within 30 days of their surgery," the researchers write.

John W. Scott, MD, MPH, from the Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts, and colleagues report their findings in an article published online April 27 in JAMA Surgery.

The investigators analyzed data on 421,476 patient emergency general surgeries from the 2008 to 2011 Hospital Cost and Utilization Project's National Inpatient Sample that were weighted to represent 2.1 million patient encounters. They included a racially and ethnically diverse group of adults aged 18 to 105 years with a diverse mix of payer status and income levels. Large hospitals made up 61.2% and urban teaching hospitals 11.8% of the hospitals in the study.

In the overall sample, the mean mortality was 1.23% (95% confidence interval [CI], 1.18% - 1.28%), and 15.0% (95% CI, 14.6% - 15.3%) of the patients had at least one complication. The average cost per hospital admission was $13,241.

The researchers included 35 distinct three-digit procedure group codes in the final analytic sample and identified 138,992 partial colectomies, 78,478 small bowel resections, 619,197 cholecystectomies, 31,571 cases of operative management of peptic ulcer disease, 102,856 surgeries for lysis of peritoneal adhesions, 682,043 appendectomies, and 9418 laparotomies.

Complications included pneumonia, deep vein thrombosis and/or pulmonary embolism, acute renal injury, stroke, myocardial infarction, cardiac arrest, acute respiratory distress syndrome, sepsis, septic shock, mechanical wound failure, wound infection, postoperative gastrointestinal tract complications, and other postoperative complications including retained foreign body and postoperative hemorrhage.

The complication rates were 42.80% for partial colectomy, 46.94% for small bowel resection, 8.06% for cholecystectomy, 42.00% for operative management of peptic ulcer disease, 28.09% for lysis of peritoneal adhesions, 7.27% for appendectomy, and 40.15% for laparotomy.

The mortality rates were 5.33% for partial colectomy, 6.47% for small bowel resection, 0.22% for cholecystectomy, 6.83% for operative management of peptic ulcer disease, 1.59% for lysis of peritoneal adhesions, 0.08% for appendectomy, and 23.76% for laparotomy.

The inpatient costs were $27,558.77 for partial colectomy, $28 450.72 for small bowel resection, $10,579.35 for cholecystectomy, $27,095.60 for operative management of peptic ulcer disease, $17,387.27 for lysis of peritoneal adhesions, $9664.30 for appendectomy, and $21,962.55 for laparotomy.

"Although cost was not used to rank the procedures, it is notable that the same 7 procedures ranked by clinical burden also accounted for 80% of all EGS-related inpatient costs," the authors write. "This finding further emphasizes the usefulness of these 7 procedures to serve as the basis for understanding ways to improve quality and reduce cost among patients undergoing EGS."

In an invited commentary, Martin G. Paul, MD, from Sibley Memorial Hospital, Johns Hopkins Medicine, Washington, DC, writes, "While this study has the limitations associated with using claims-derived data, the next step would be to monitor the outcomes of these 7 operative EGS procedures in prospective, clinically derived databases, particularly those procedures that Scott et al have defined as being associated with the highest rates of complications, such as emergency bowel resection and surgery for the acute complications of ulcer disease."

The study contributes important information to the literature aimed at improving outcomes and reducing costs in caring for patients with intra-abdominal emergencies, and expands on the efforts of the American Association for the Surgery of Trauma that initially standardized definitions and diagnosis codes for EGS, Dr Paul adds.

"Continued studies along these lines should provide direction for high-impact quality initiatives, emphasizing not just a reduction in complications but an earlier recognition of these particularly morbid adverse events. Also necessary are improved metrics for measuring the quality of the acute surgical care that is delivered, so that this can be better standardized across our health care system. Finally, national health policy needs to address the fact that we have a decreasing number of general surgeons facing a growing burden, and appropriate resources and strategic planning need to be directed toward correcting this," Dr Paul explains.

One coauthor reports being the principal investigator of a contract with the Patient-Centered Outcomes Research Institute and a Harvard Surgery Affinity Research Collaborative Program grant; he also reports being the cofounder and an equity holder in Patient Doctor Technologies Inc. The remaining authors and commentator have disclosed no relevant financial relationships.

JAMA Surg. Published online April 27, 2016. Article full text, Commentary extract

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