The impact of acute care surgery on appendicitis outcomes

Abstract

Background Acute appendicitis is the most common indication for emergency general surgery (EGS) in the US. We examined the role of acute care surgery (ACS) on interventions and outcomes for acute appendicitis at a national sample of university-affiliated hospitals. Methods We surveyed senior surgeons responsible for EGS coverage at University HealthSystems Consortium (UHC) hospitals, representing >90% of university-affiliated hospitals in the US. The survey elicited data on resources allocated for EGS during 2013. Responses were linked to UHC outcomes data by unique hospital identifiers. Patients treated at hospitals reporting hybrid models for EGS coverage were excluded. Differences in interventions and outcomes between patients with acute appendicitis treated at ACS hospitals vs. hospitals with a general surgeon on-call model (GSOC) were analyzed using univariate comparisons and multivariable logistic regression models adjusted for patient demographics, clinical acuity, and hospital characteristics. Results We found 122 hospitals meeting criteria for analysis where 2,565 patients were treated for acute appendicitis. 48% of hospitals had an ACS model (N =1414), and 52% had a GSOC model (N=1151). Hospitals with ACS models were more likely to treat minority patients with greater severity of illness than GSOC models. Patients treated at ACS hospitals were more likely to undergo laparoscopic appendectomy. In multivariable modeling of patients who had surgery (N=2,258), patients treated at ACS hospitals had 1.86 [95%CI 1.23,2.80] greater odds of undergoing laparoscopic appendectomy. Conclusion In an era when laparoscopic appendectomy is increasingly accepted for treating uncomplicated acute appendicitis, particularly in low risk patients, it is concerning that patients treated at GSOC model hospitals are more likely to undergo traditional open surgery despite having less severity of illness at the time of presentation. Furthermore, hospitals with ACS are functioning as safety net hospitals for vulnerable patients with acute appendicitis. Level of Evidence III

Clinical practice selectively follows acute appendicitis guidelines

“…Clinician availability may reduce the oversight required for timely termination of perioperative antibiotics, in the absence of an established pathway, or advanced practice provider (APP) to help guide care. These aspects likely contributed to the low frequency of an enhanced recovery after surgery (ERAS) approach that includes same day discharge for uncomplicated appendicitis in otherwise healthy adults [45,46]. Nonetheless, our data demonstrate that practice can conform to guideline-based recommendations-which suggests the lack of an evidence-to-practice gap-across very different healthcare systems (USA, Estonia, Romania), at least in participating centers.…”

“…Clinician availability may reduce the oversight required for timely termination of perioperative antibiotics, in the absence of an established pathway, or advanced practice provider (APP) to help guide care. These aspects likely contributed to the low frequency of an enhanced recovery after surgery (ERAS) approach that includes same day discharge for uncomplicated appendicitis in otherwise healthy adults [ 45 , 46 ].…”

Disparities in access to emergency general surgery care in the United States

“…69,70 This model,however has been viewed largely from the perspective of the proponets of the acute care paradigm as an isolated, hospital-based service line; but, our prior research suggests that the resource intensiveness of a round-the-clock acute care surgery service may not be practical at all hospitals, in particular, the smaller hospitals lacking a trauma center caable of providing 24/7 coverge. 71,72 Therefore, this paradigm of acute care surgery should be understood, by surgeon leaders, hospital administrators, and regional public health officials alike, as a network for patients presenting for EGS care centered around an EGS Center of Excellence (i.e., the hospitals with an acute care surgery service).…”

Geographic Diffusion and Implementation of Acute Care Surgery

“…In this study, we found that while ACS implementation is increasing, uptake is uneven across regions. Yet early reports from hospitals adopting ACS suggest a number of improvements in quality, costs, and outcomes including optimal OR use, reduced length of stay, and improved mortality . Furthermore, regional studies indicate that patients with general surgery emergencies may have specific demographic, comorbid, and physiologic risk factors that warrant early referral to ACS hospitals with constant OR preparedness and specialized critical care resources .…”