Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions

Abstract

IMPORTANCE Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement. OBJECTIVE To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions. DESIGN, SETTING, AND PARTICIPANTS This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019. EXPOSURES Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction. MAIN OUTCOMES AND MEASURES One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year. RESULTS A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004). CONCLUSIONS AND RELEVANCE In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

“…Until recently patients undergoing emergency general surgery including emergency laparotomy have been a relatively overlooked group [ 15 ]. Just under a decade ago, major cohort studies reported 30-day mortality for emergency laparotomy of between 14 and 18.5% rising to over 25% in patients over 80 years of age [ 14 , 18 , 19 ].…”

Older adults' perspectives 3 months after emergency general surgery highlight opportunities to improve care

“…1 For those who survive the index hospitalization, more than half are rehospitalized in the year after discharge, and one in three die. 1 Although surgical quality improvement initiatives have largely focused on reducing complications and mortality in the acute perioperative period, 2 patients' long-term needs beyond this 30-day window remain understudied and the lived experience from the patient perspective poorly understood. To address this gap, we qualitatively explored factors contributing to or impeding recovery as experienced by older adults 3 months post-EGS.…”

Frailty in older patients undergoing emergency colorectal surgery: USA National Surgical Quality Improvement Program analysis

“…Older adults have accompanying co‐morbidities that place them at significantly higher risk of postoperative mortality, morbidity, use of intensive care resources and a longer hospital stay after emergency surgery 4–8 . It is becoming increasingly important to formally assess elderly patients for challenges to their functional status due to frailty 9–11 . Frailty is a measure of increased vulnerability and decreased physiological reserve to stressors, such as surgery, which impairs recovery and return to preoperative functional level 12,13 .…”