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Defining Operative Emergency General Surgery

Defining Operative Emergency General Surgery
Author Information (click to view)

Joaquim M. Havens, MD

Director of Emergency General Surgery

Center for Surgery and Public Health

Brigham & Women’s Hospital

Instructor in Surgery

Harvard Medical School

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Joaquim M. Havens, MD (click to view)

Joaquim M. Havens, MD

Director of Emergency General Surgery

Center for Surgery and Public Health

Brigham & Women’s Hospital

Instructor in Surgery

Harvard Medical School

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A national study has found that the vast majority of all operative volume, complications, deaths, and costs associated with emergency general surgery are attributable to seven procedures. The findings may help hospitals focus prevention efforts and quality improvement initiatives.
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More than 3 million Americans are admitted to hospitals in the United States each year for emergency general surgery (EGS), and this patient population is a particularly high-risk group of surgery patients. According to clinical trials, patients who undergo an EGS operation are up to six times more likely to die after surgery than are those undergoing the same procedures as an elective surgery. In addition, about 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. EGS patients account for more than $6 billion in annual costs to the U.S. healthcare system.

Despite the inordinate burden of EGS, few studies have attempted to create surgical benchmarks for these procedures. In 2013, the American Association for the Surgery of Trauma addressed this issue by publishing a landmark list of 621 ICD-9 diagnosis codes to include any patient requiring an emergency surgical evaluation for diseases within the realm of general surgery as defined by the American Board of Surgery. A follow-up study proposed 149 ICD codes that were identified as procedures that would or could treat any EGS diagnosis.

A Retrospective Review

To build on this broadly inclusive list of EGS diagnoses, a more focused and nationally representative list of EGS procedures is needed. For a study published in JAMA Surgery, Joaquim M. Havens, MD, and colleagues set out to define a set of procedures that accounted for at least 80% of the national burden of operative EGS. “This data may help simplify efforts to establish EGS benchmarks and guide standardized and focused research priorities,” says Dr. Havens. “It can also inform the development of quality improvement programs that aim to lower morbidity, mortality, and costs.”

For the study, Dr. Havens and colleagues conducted a retrospective review using data from the 2008-2011 National Inpatient Sample. Adults with primary EGS diagnoses who were admitted urgently or emergently and who underwent an operation within 2 days of admission were included in the analysis. Among ranked procedures, contributions to total EGS frequency, mortality, and hospital costs were assessed. In total, the study identified more than 420,000 patient encounters that were associated with operative EGS. These were then weighted to represent 2.1 million encounters across the country over a 4-year period.

Important Findings

According to the study results, the overall mortality rate was about 1.2%, the complication rate was 15.0%, and the average cost per admission was $13,241. After ranking 35 procedure groups by contribution to EGS mortality and morbidity burden, a final set of seven operative EGS procedures collectively accounted for 80.0% of procedures, 80.3% of deaths (Figure), 78.9% of complications, and 80.2% of inpatient costs nationwide. These surgeries included partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy.

“It’s important to note that our findings were based on a nationally representative data set that includes patients of all ages, races and ethnicities, income levels, facility types, and geographic regions,” Dr. Havens says. “It’s notable that the same seven procedures accounted for the greatest number of EGS cases, deaths, complications, and inpatient costs. Knowing the impact that these procedures have on hospitals, we now have a basis for finding ways to improve quality of care and reduce the burden experienced by patients undergoing EGS, perhaps with stronger prevention efforts.”

Examining Implications

According to Dr. Havens, national quality benchmarks and cost reduction efforts should focus on the seven common, complicated, and costly EGS procedures identified in the study. “Our findings build on important prior work that has sought to define EGS,” he says. “Given the high national prevalence and the high proportion of burden that the seven EGS procedures identified in our study represent, deriving EGS benchmarks for this care could lead to better clinical decision making, reduce costs, and improve patient outcomes.”

Dr. Havens and colleagues point out in their study that focusing on a subset of important procedures like the seven EGS procedures identified in the study aligns with recent efforts like the Surgical Care Improvement Project, the American College of Surgeons’ National Surgical Quality Improvement Program, and the Society of Thoracic Surgeons’ quality benchmarks. “These programs are all focused on patients who have undergone one of a specific, clearly defined set of procedures,” says Dr. Havens. “Applying similar measures to the EGS procedures identified in our analysis may be valuable because they can guide surgeons and hospitals in improving patient care throughout the U.S.”

Joaquim M. Havens, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Readings & Resources (click to view)

Scott JW, Olufajo OA, Brat GA, et al. Use of national burden to define operative emergency general surgery. JAMA Surg. 2016 Apr 27 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=2516780.

Havens JM, Peetz AB, Do WS, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015;78:306-311.

Havens JM, Peetz AB, Do WS, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015;78:306-311.

Shah AA, Haider AH, Zogg CK, et al. National estimates of predictors of outcomes for emergency general surgery. J Trauma Acute Care Surg. 2015;78:482-491.

Gale SC, Shafi S, Dombrovskiy VY, Arumugam D, Crystal JS. The public health burden of emergency general surgery in the United States: a 10-year analysis of the Nationwide Inpatient Sample—2001 to 2010. J Trauma Acute Care Surg. 2014;77:202-208.

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