Better Survival After Geriatric Emergency Surgery Seen With Higher Hospital Operative Volume

By Will Boggs MD

April 29, 2019

NEW YORK (Reuters Health) - Geriatric patients who have emergency surgery at hospitals with higher operative volumes fare better than those operated at lower-volume hospitals, according to a retrospective study.

Emergency surgery in older patients is associated with higher morbidity and mortality than is elective operations, and as many as 44% of operations in older persons are emergent.

To investigate if hospital emergency operative volume matters, Dr. Robert D. Becher from Yale School of Medicine, in New Haven, Connecticut, and colleagues used data from the State Inpatient Database of California and the American Hospital Association Annual Survey of Hospitals Database.

They evaluated data from 299 hospitals on close to 42,000 operations. Among 10 common surgeries they considered, the three highest-volume operations were cholecystectomy, colectomy and appendectomy, and the three lowest-volume were umbilical-hernia repair, excision of necrotizing soft-tissue infection (NSTI) and repair of perforated-peptic-ulcer disease.

Overall unadjusted mortality varied from 0.6% for appendectomy to 14.2% for colectomy and 17.7% for repair of perforated peptic ulcer disease, the researchers report in the Journal of the American College of Surgeons, online April 18.

Risk-adjusted mortality decreased significantly as operative volume increased for all 10 emergency general surgery operations, and in regression models, hospital operative volume was the most important characteristic with significant impact on mortality for every operation studied.

Hospital operative-volume thresholds at which there was a 95% chance that that institution performed at or better than the average risk-adjusted mortality rate ranged from 38 cases over two years for colectomy to five cases over two years for umbilical-hernia repair.

More than 50% of hospitals, on average, did not meet the volume-thresholds, representing 22% of patients.

The number of hospitals failing to meet the threshold mortality standards ranged from 30% of all hospitals for cholecystectomy to 81% of hospitals for repair of perforated-peptic-ulcer disease. The number of operations performed at these below-threshold institutions ranged from 7% of all cases for cholecystectomy to 64% of all operations for repair of perforated-peptic-ulcer disease.

"To lessen the negative impact of the wide variation in survival rates at lower volume hospitals, geriatric patients may benefit from a formal system of emergency surgical care that consolidates operative emergencies to higher volume accredited surgery centers, as defined by the volume-threshold benchmark," the researchers conclude.

"Further investigation needs to be conducted to define and validate other important determinants of morbidity and mortality in geriatric patients undergoing surgical emergencies," they add.

Dr. Daniel I. McIsaac of the University of Ottawa, in Canada, who recently identified frailty as a predictor of death in older people undergoing surgery, told Reuters Health by email, "The authors look at whether above a certain 'ceiling' outcomes are better, but I think the real question is where do outcomes get worse than average, not better. Since this is an observational study with a relatively large sample, there are still some surgeries with low numbers of total cases, so it is hard to draw any strong conclusions either way."

"There's also the issue of what a patient or clinician does with these findings," he said. "When surgeries are done on a planned (i.e., elective basis) there is more opportunity to take advantage of high-volume/center of excellence hospitals, or to at least weigh the benefits of going to a high-volume center (like possibly better outcomes) vs. the downsides (possibly having to travel farther from home, having less social support, etc.)."

"Changing or choosing a hospital when someone is already acutely sick is a different challenge," Dr. McIsaac said. "When someone is already sick and needs an emergency surgery, they may not be stable enough to change hospitals, and there is also evidence that delaying emergency surgery may contribute to bad outcomes in some cases. So at this point, an observational study like this doesn't really provide evidence that would change practice."

He added, "There is a group of surgeons asking for a no-low-volume surgery pledge. This may be feasible in an urban setting with lots of hospitals or for planned surgery, but if you need emergency surgery in a rural area, a low-volume hospital may be much better than no hospital at all. So this is still an evolving issue in practice and policy."

Dr. Becher did not respond to a request for comments.

SOURCE: https://bit.ly/2ZBKVZn

J Am Coll Surg 2019.

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