Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team

Christopher T. Aquina, MD, MPH; Adan Z. Becerra, BA; Christian P. Probst, MD, MPH; Zhaomin Xu, MD; Bradley J. Hensley, MD, MBA; James C. Iannuzzi, MD, MPH; Katia Noyes, PhD, MPH; John R. T. Monson, MD; Fergal J. Fleming, MD

Disclosures

Annals of Surgery. 2016;264(3):437-447. 

In This Article

Abstract and Introduction

Abstract

Objective: To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions.

Summary Background Data: Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies.

Methods: Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions.

Results: Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32).

Conclusions: This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.

Introduction

Adhesive small bowel obstruction (SBO) is a common and costly condition following abdominal surgery.[1,2] The complication occurs in up to a third of postoperative patients, typically requiring inpatient admission. It is one of the most frequently treated conditions in US hospitals, has a 30-day readmission rate of 16%, and is often a chronic, recurrent problem.[3–5] Furthermore, 1 million inpatient days and $2 billion was spent on admissions for adhesion-related disease in 2005 alone in the United States.[6] Finally, adhesive-SBO is associated with high morbidity and a mortality rate as high as 10%.[7]

Overall, 65% to 80% of patients with adhesive-SBO are successfully managed without surgical intervention.[8–11] For this reason, many patients are admitted to a primary medical service (MS) managed by hospitalists instead of a surgical service (SS). To date, only 4 studies have evaluated the impact of admitting service on healthcare utilization and outcomes for patients with adhesive-SBO. Each of the studies demonstrated a shorter time to surgery, which is associated with lower complication and mortality rates, for patients admitted to a SS compared with an MS.[12–15] However, each of these studies were small, single-institution retrospective reviews and had conflicting results with respect to the impact of admitting service on other utilization measures and outcomes. As a result, current data provide limited insight to guide institutional policies regarding which service should primarily manage these patients.

Given these limitations, we compared several healthcare utilization measures and outcomes between primary MSs and SSs for patients admitted with adhesive-SBO using a large, population-based dataset. Stratifying the analyses into nonoperative and operative management, we hypothesized that a primary MS would be associated with longer length of stay (LOS), higher cost, and higher 30-day readmission rates as well as a delay in time to operation and higher mortality rates following operative intervention.

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