Seven procedures account for 80% of emergency general surgery operations, deaths, and complications, US study finds

BMJ 2016; 353 doi: (Published 03 May 2016) Cite this as: BMJ 2016;353:i2498
  1. Michael McCarthy
  1. Seattle

Each year more than half a million patients in the United States undergo urgent or emergency general surgery at an annual cost of more than $6bn (£4.1bn; €5.2bn), but just seven procedures account for 80% of these operations and related deaths, surgical complications, and costs, a new study has found.

The seven most costly emergency general surgery procedures identified by the study were partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy. “These first 7 procedure groups accounted for 80.0% of all procedures, 80.3% of all deaths, 78.9% of all complications, and 80.2% of all inpatient costs in this nationally,” the researchers, led by John W Scott of Brigham and Women’s Hospital, Boston, reported in JAMA.1

The researchers analyzed data from the National Inpatient Sample, a nationally representative database of hospital admissions, from 2008 to 2011. From this database they identified a sample of 421 476 patient encounters in which the diagnosis involved emergency general surgery. The weighted sample represented over 2.1 million patient encounters over the four years.

The study included all patients 18 years or older who had a principal diagnosis consistent with emergency general surgery. These were patients who were admitted urgently or in an emergency, directly or through the emergency department, and who underwent an operative procedure on the day of admission or the day after. Patients who underwent obstetric, cardiac, vascular, endovascular, or endoscopic procedures were excluded.

The researchers assessed morbidity by identifying 13 complications: pneumonia, deep vein thrombosis 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, or other postoperative complications, including retained foreign body and postoperative hemorrhage.

The researchers found that the mean mortality in the overall sample was 1.23% (95% confidence internal 1.18% to 1.28%), and 15% (14.6% to 15.3%) of patients experienced at least one complication. The average impatient cost per admission was $13 241 ($12 957 to $13 525), ranging from $9664.30 for appendectomy to $28 450.72 for small bowel resection.

The researchers concluded, “National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS [emergency general surgery] procedures.”

In an invited commentary, Martin G Paul, of Sibley Memorial Hospital, Washington, DC, noted that the costs of emergency general surgery exceeded those of treating diabetes, myocardial infarction, and new cancer diagnoses.2 “What is now a national burden will soon become a crisis, with annual costs projected to reach more than $40 billion in 2060,” he wrote.

Public policy has been slow to deal with this “looming catastrophe,” Martin wrote, in part because of a lack of data needed to characterize and measure the scope and impact of these procedures—a lack, he said, partly met by Scott and colleagues’ paper. “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,” he wrote.


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