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Non-Operative Management in Emergency General Surgery: Does It Matter for Surgical Quality Benchmarking in Older Adults?
*Manuel Castillo-Angeles, Ali Salim, *Joaquim M. Havens
Surgery, Brigham and Women's Hospital, Brookline, Massachusetts
Objective: Higher hospital operative volume is linked to better patient outcomes after emergency general surgery (EGS). However, there is an increasing number of patients being managed non-operatively, particularly among older adults. This portion of the surgical population has always been excluded from quality benchmarking. A hospital operative-to-non-operative management ratio (ONR) might reflect the balance between surgical intervention and conservative care and may serve as a better marker of hospital quality. Quality assessment has traditionally relied on morbidity/mortality, but these may not fully capture institutional practice patterns nor what matters most to older adults (i.e., their ability to return home). Therefore, we aimed to assess the association between ONR and home discharge for older adults undergoing EGS.
Methods: This was a retrospective analysis of the National Inpatient Sample database (2015-2018). For each hospital, we calculated a risk-adjusted ONR for adults >=65 years with common EGS diagnoses (diverticulitis, bowel obstruction, acute pancreatitis, peptic ulcer, ischemic bowel, appendicitis, and cholecystitis), and who underwent urgent/emergent surgery within 48 hours. As a commonly used metric, hospital operative volume was also calculated to serve as comparison to ONR. Both metrics were then divided into tertiles (Low, Middle, and High). Our primary outcome was home discharge. Adjusting for patient and hospital characteristics, multivariable regression analyses evaluated the impact of increasing ONR/Hospital operative volume on our main outcome.
Results: Among 1,470,114 EGS admissions across 4,851 hospitals, 207,270 (14.1%) older adults underwent an EGS procedure. The mean ONR was 0.28 (SD 0.07), with a two-fold difference between the 10th and 90th percentile of hospitals, underscoring marked variation in practice patterns. Mean ONR across tertiles were 0.20 (SD 0.05) [Low], 0.28 (SD 0.01) [Middle], and 0.36 (SD 0.04) [High]. Mean hospital operative volume across tertiles were 30.21 (SD 12.9) [Low], 66.35 (SD 10.0) [Middle], and 118.32 (SD 29.5) [High]. After adjusted analysis, care at hospitals within the highest ONR tertile was significantly associated with higher odds of home discharge (OR 1.12, 95%CI 1.09-1.15) (Table). Hospital operative volume was not associated with discharge to home.
Conclusion: An increased hospital operative-to-non-operative management ratio of EGS conditions in the geriatric population is strongly associated with increased odds of a favorable discharge home. This study demonstrates that to better understand hospital quality as it pertains to EGS patient outcomes we need to include operative and non-operative cases and evaluate risk adjusted outcomes that are important to this patient population. The ONR is a novel metric that captures practice patterns within and across hospitals which can highlight variation in management and drive targeted interventions towards patient-centered goals.
Impact of increasing ONR/Hospital operative volume on home discharge.
| | Home Discharge |
| | OR | 95% CI | p-value |
| Hospital operative-to-non-operative management ratio | | | |
| Low | Reference |
| Middle | 1.02 | 0.99 - 1.05 | 0.080 |
| High | 1.12 | 1.09 - 1.15 | <0.001 |
| Hospital operative volume | | | |
| Low | Reference |
| Middle | 0.98 | 0.96 - 1.01 | 0.327 |
| High | 0.99 | 0.96 - 1.02 | 0.571 |
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