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Original Investigation |

Use of National Burden to Define Operative Emergency General Surgery Online Only

John W. Scott, MD, MPH1; Olubode A. Olufajo, MD, MPH1,2; Gabriel A. Brat, MD2; John A. Rose, MD, MPH1; Cheryl K. Zogg, MSPH, MHS1; Adil H. Haider, MD, MPH1,2; Ali Salim, MD1,2; Joaquim M. Havens, MD1,2
[+] Author Affiliations
1Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
2Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
JAMA Surg. 2016;151(6):e160480. doi:10.1001/jamasurg.2016.0480.
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Importance  Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures.

Objective  To define a set of procedures accounting for at least 80% of the national burden of operative EGS.

Design, Setting, and Participants  A retrospective review was conducted using data from the 2008-2011 National Inpatient Sample. Adults (age, ≥18 years) with primary EGS diagnoses consistent with the American Association for the Surgery of Trauma definition, admitted urgently or emergently, who underwent an operative procedure within 2 days of admission were included in the analyses. Procedures were ranked to account for national mortality and complication burden. Among ranked procedures, contributions to total EGS frequency, mortality, and hospital costs were assessed. The data query and analysis were performed between November 15, 2015, and February 16, 2016.

Main Outcomes and Measures  Overall procedure frequency, in-hospital mortality, major complications, and inpatient costs calculated per 3-digit International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes.

Results  The study identified 421 476 patient encounters associated with operative EGS, weighted to represent 2.1 million nationally over the 4-year study period. The overall mortality rate was 1.23% (95% CI, 1.18%-1.28%), the complication rate was 15.0% (95% CI, 14.6%-15.3%), and mean cost per admission was $13 241 (95% CI, $12 957-$13 525). After ranking the 35 procedure groups by contribution to EGS mortality and morbidity burden, a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide. These 7 procedures included partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy.

Conclusions and Relevance  Only 7 procedures account for most admissions, deaths, complications, and inpatient costs attributable to the 512 079 EGS procedures performed in the United States each year. National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures.

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Figure 1.
Creation of Operative Emergency General Surgery Cohort

Data were obtained from the National Inpatient Sample for admissions between 2008 and 2011.16 AAST indicates American Association for the Surgery of Trauma; EGS, emergency general surgery; and HD, hospital day.

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Figure 2.
Cumulative National Burden of Emergency General Surgery Procedures, by Rank

Each line represents the proportion of cumulative national burden of procedure volume, patient deaths, complications, and costs. The vertical dotted line delineates the top 7 ranked procedures, which accounted for approximately 80% of all cumulative burden. Data were obtained from the National Inpatient Sample for admissions between 2008 and 2011.16

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Figure 3.
Comparison of Mortality and Complication Rates With Procedure Volume

Association between mortality (A) and complication (B) rates and the volume of procedures. Data were obtained from the National Inpatient Sample for admissions between 2008 and 2011.16 PUD indicates peptic ulcer disease.

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