Publications by authors named "Joaquim M Havens"

72 Publications

Frailty Assessment and Shared Decision-making-Reply.

JAMA Surg 2021 May 12. Epub 2021 May 12.

Division of Trauma, Burn, and Surgical Critical Care, Surgery Department, Brigham and Women's Hospital, Boston, Massachusetts.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2021.1473DOI Listing
May 2021

Non-technical skill assessments across levels of US surgical training.

Surgery 2021 Apr 1. Epub 2021 Apr 1.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland. Electronic address:

Background: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool.

Methods: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression.

Results: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories.

Conclusion: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2021.02.058DOI Listing
April 2021

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

World J Surg 2021 May 6;45(5):1272-1290. Epub 2021 Mar 6.

Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds.

Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-021-05994-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026421PMC
May 2021

Quantifying lives lost due to variability in emergency general surgery outcomes: Why we need a national emergency general surgery quality improvement program.

J Trauma Acute Care Surg 2021 04;90(4):685-693

From the Department of Surgery (Z.G.H., M.P.J., J.M.H., E.G., Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (J.W.S.), University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine (E.G.), Brigham and Women's Hospital, Boston, Massachusetts; and The Dean's Office, Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan.

Background: Nearly 4 million Americans present to hospitals with conditions requiring emergency general surgery (EGS) annually, facing significant morbidity and mortality. Unlike elective surgery and trauma, there is no dedicated national quality improvement program to improve EGS outcomes. Our objective was to estimate the number of excess deaths that could potentially be averted through EGS quality improvement in the United States.

Methods: Adults with the American Association for the Surgery of Trauma-defined EGS diagnoses were identified in the Nationwide Emergency Department Sample 2006 to 2014. Hierarchical logistic regression was performed to benchmark treating hospitals into reliability adjusted mortality quintiles. Weighted generalized linear modeling was used to calculate the relative risk of mortality at each hospital quintile, relative to best-performing quintile. We then calculated the number of excess deaths at each hospital quintile versus the best-performing quintile using techniques previously used to quantify potentially preventable trauma deaths.

Results: Twenty-six million EGS patients were admitted, and 6.5 million (25%) underwent an operation. In-hospital mortality varied from 0.3% to 4.1% across the treating hospitals. Relative to the best-performing hospital quintile, an estimated 158,177 (153,509-162,736) excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort.

Conclusion: Nearly 200,000 excess EGS deaths occur across the United States each decade. A national initiative to enable structures and processes of care associated with optimal EGS outcomes is urgently needed to achieve "Zero Preventable Deaths after Emergency General Surgery."

Level Of Evidence: Care management, level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000003074DOI Listing
April 2021

Association of Frailty With Morbidity and Mortality in Emergency General Surgery by Procedural Risk Level.

JAMA Surg 2021 Jan;156(1):68-74

Division of Trauma, Burn, and Surgical Critical Care, Surgery Department, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: In this aging society, older patients are more commonly undergoing emergency general surgery (EGS). Although frailty has been associated with worse outcomes in this population, EGS encompasses a heterogeneous mix of procedures.

Objective: To determine if the association of frailty with morbidity and mortality in EGS patients varies based on the level of procedural risk.

Design, Setting, And Participants: This cross-sectional study analyzed Medicare inpatient claims file (January 2007-December 2015) and included all inpatients who underwent 1 of 7 previously described EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Analysis took place from September 2019 to January 2020.

Exposures: The primary exposure of interest was risk procedural level. EGS procedures were stratified as high risk (excision of small intestine, excision of large intestine, peptic ulcer repair, lysis of peritoneal adhesions, and laparotomy) and low risk (appendectomy and cholecystectomy).

Main Outcomes And Measures: The primary outcome was overall 30-day mortality after discharge. Frailty was assessed using a claims-based frailty index. Multivariate logistic regression analysis was used and was stratified by risk level.

Results: A total of 882 929 EGS patients were included in this study (mean [SD] age, 77.9 [7.5] years; 483 637 [54%] were female). Overall mortality was 4.5% (n = 40 304). The frailty index classified 12.6% (n = 111 513) of patients as frail, and mortality within this group was 9.9% (n = 11 307). High-risk procedures represented 53% (n = 468 098) of the caseload, and mortality was 6.8% (n = 31 979). For low-risk procedures, mortality was 2% (n = 8325). Frailty was significantly associated with mortality (odds ratio, 1.64; 95% CI, 1.60-1.68). After stratified analysis, this association remained significant for high-risk (odds ratio, 1.53; 95% CI, 1.49-1.58) and low-risk (odds ratio, 2.05; 95% CI, 1.94-2.17) procedures.

Conclusions And Relevance: Frailty was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2020.5397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689563PMC
January 2021

Training Novice Raters to Assess Nontechnical Skills of Operating Room Teams.

J Surg Educ 2021 Mar-Apr;78(2):386-390. Epub 2020 Aug 13.

Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Objective: To our knowledge, no curricula have been described for training novice, nonclinician raters of nontechnical skills in the operating room (OR). We aimed to report the reliability of Oxford Non-Technical Skills (NOTECHS) ratings provided by novice raters who underwent a scalable curriculum for learning to assess nontechnical skills of OR teams.

Design: In-person training course to apply the NOTECHS framework to assessing OR teams' nontechnical skill performance, led by 2 facilitators and involving 5 partial-day sessions of didactic presentations, video simulation, and live OR observation with postassessment debriefing. NOTECHS ratings were submitted after each of 11 video scenarios and 8 live operations for the total NOTECHS team rating (including surgical/anesthesiology/nursing subteams) and for each NOTECHS skill category-situation awareness, problem solving and decision making, teamwork and cooperation, leadership and management. Inter-rater reliability was determined by calculating the intraclass correlation coefficient (ICC, range 0-1).

Setting: Training for outcome measurement during a quality improvement initiative focused on surgical safety in 3 public hospitals in Singapore. Two trainings were conducted in May 2019 and January 2020.

Participants: Ten novice raters who were existing hospital staff and had overall minimal OR experience and no prior experience with nontechnical skill assessment.

Results: ICC for the total NOTECHS team rating was 0.89 (95% confidence interval [CI], 0.87-0.91). ICCs for each NOTECHS category were as follows: situation awareness, 0.83 (95% CI, 0.78-0.88); problem solving and decision-making, 0.76 (95% CI, 0.70-0.83); teamwork and cooperation, 0.84 (95% CI, 0.79-0.88); leadership and management, 0.81 (95% CI, 0.75-0.86).

Conclusions: This training curriculum for nontechnical skill assessments of OR teams was associated with high inter-rater reliability from novice raters with minimal collective OR experience. Using scalable training materials to produce reliable measurements of OR team performance, this nontechnical skills assessment curriculum may contribute to future QI projects aimed at improving surgical safety.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsurg.2020.07.042DOI Listing
August 2020

Care Discontinuity in Emergency General Surgery: Does Hospital Quality Matter?

J Am Coll Surg 2020 06 27;230(6):863-871. Epub 2020 Feb 27.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Background: Changes in care providers and hospitals after emergency general surgery (EGS) (care discontinuity) are associated with increased morbidity and mortality. The cause of these worse outcomes is unknown. Our goal was to determine if hospital quality is associated with mortality after readmissions independent of continuity in care.

Study Design: This was a retrospective analysis of Medicare inpatient claims (2007 to 2015). All inpatients older than 65 years of age who underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally, were included. Care discontinuity was defined as readmission within 30 days to a nonindex hospital. Hospital quality was determined by hospital-level, risk-adjusted mortality rates by EGS procedure and categorized into high quality (HQ) and low quality (LQ). The primary outcome was overall mortality. Multivariate logistic regression analysis was used to determine the association of discontinuity and mortality.

Results: There were 882,929 EGS patients, 87,232 of whom were readmitted within 30 days of discharge. Care discontinuity was independently associated with mortality (odds ratio [OR] 1.23; 95% CI 1.17 to 1.29). When readmitted patients were stratified by quality of index and readmitting hospital, mortality was associated with the quality of both the index hospital and the readmitting hospital. The highest mortality rate was observed in patients with index admission at low-quality hospitals and readmission to a different low-quality hospital.

Conclusions: Both care discontinuity and hospital quality are independently associated with mortality in EGS patients. These data support maintaining continuity of care, even at low performing hospitals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2020.02.025DOI Listing
June 2020

Risk Prediction Accuracy Differs for Transferred and Nontransferred Emergency General Surgery Cases in the ACS-NSQIP.

J Surg Res 2020 03 22;247:364-371. Epub 2019 Nov 22.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Risk prediction accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator has been shown to differ between emergency and elective surgery. Benchmarking methods of clinical performance require accurate risk estimation, and current methods rarely account for admission source; therefore, our goal was to assess whether the ACS-NSQIP predicts mortality comparably between transferred and nontransferred emergency general surgery (EGS) cases.

Materials And Methods: This is a retrospective study using the ACS-NSQIP database from 2005 to 2014including all inpatients who underwent one of seven previously described EGS procedures. The admission source was classified as directly admitted versus transferred from an outside emergency room or an acute care facility. We compared the accuracy of ACS-NSQIP-predicted mortality probabilities using the observed-to-expected (O:E) ratio and Brier score. A subgroup analysis was performed to compare accuracy of high-risk and low-risk procedures.

Results: A total of 206,103 EGS admissions were identified, of which 6.97% were transfers. Overall mortality was 3.26% for the entire cohort and 10.24% within the transfer group. The O:E ratios generated by ACS-NSQIP models differed between transferred patients (O:E = 1.0, 95% confidence interval = 0.97-1.02) and nontransferred patients (O:E = 1.12, 95% confidence interval = 1.09-1.14). The Brier score for transferred patients was greater than that for nontransferred patients (0.063 versus 0.018, respectively) showing higher accuracy for nontransferred patients.

Conclusions: The ACS-NSQIP risk estimates used for benchmarking differ between transferred and nontransferred EGS cases. Analyses of the Brier score by the ACS-NSQIP risk calculator demonstrated inferior prediction for transferred patients. This increased burden on accepting institutions will have an impact on quality metrics and should be considered for benchmarking of clinical performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2019.10.007DOI Listing
March 2020

Emergency General Surgery Volume and Its Impact on Outcomes in Military Treatment Facilities.

J Surg Res 2020 03 4;247:287-293. Epub 2019 Nov 4.

Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers.

Materials And Methods: We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes.

Results: We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98).

Conclusions: EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2019.08.030DOI Listing
March 2020

The Impact of Income on Emergency General Surgery Outcomes in Urban and Rural Areas.

J Surg Res 2020 01 12;245:629-635. Epub 2019 Sep 12.

Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients.

Materials And Methods: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]).

Results: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52).

Conclusions: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2019.08.010DOI Listing
January 2020

Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction.

J Trauma Acute Care Surg 2019 09;87(3):630-635

From the Division of Trauma, Burns, Surgical Critical Care and Emergency General Surgery, Brigham and Women's Hospital, Boston, Massachusetts (H.G.L., M.C-A., M.B., Z.C., D.N., S.L.N., R.A., E.K., N.S., R.R., A.S., J.M.H.).

Background: Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge.

Methods: A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management.

Results: There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts.

Conclusion: Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions.

Level Of Evidence: Therapeutic study, level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002401DOI Listing
September 2019

Lower education and income predict worse long-term outcomes after injury.

J Trauma Acute Care Surg 2019 Jul;87(1):104-110

From the Center for Surgery and Public Health (J.P.H-E., A.T., S.S.A.R. A.H.H), Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health. Boston, Massachusetts; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (A.J.S., J.W.S., J.M.H., A.S., A.H.H., D.N.), Brigham and Women's Hospital, Harvard Medical School. Boston, Massachusetts; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (R.R., G.K.), Boston University School of Medicine. Boston, Massachusetts; and Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (G.V.), Massachusetts General Hospital, Harvard Medical School. Boston, Massachusetts.

Background: Lower socioeconomic status (SES) is known to be associated with higher morbidity and mortality following injury. However, the impact of individual SES on long-term outcomes after trauma is unknown. The objective of this study was to determine the impact of educational level and income on long-term outcomes after injury.

Methods: Trauma patients with moderate to severe injuries admitted to three Level-I trauma centers were contacted 6 months to 12 months after injury to evaluate functional status, return to work/school, chronic pain, and posttraumatic stress disorder (PTSD). Lower SES status was determined by educational level and income. Adjusted logistic regression models were built to determine the association between educational level and income (lowest vs. highest quartile determined by census-tract area) on each of the long-term outcomes. A sensitivity analysis was performed using the national median household income ($57,617) as threshold for defining low versus high income.

Results: A total of 1,516 patients were followed during a 36-month period. Forty-nine percent had a low educational level, and 26% were categorized in the low-income group. Mean (SD) age and injury severity score were 60 (21.5) and 14.3 (7.3), respectively, with most patients (94%) having blunt injuries. After adjusting for confounders, low educational level was associated with poor long-term outcomes: functional limitation [odds ratio (OR), 1.78 (95% confidence interval (CI), 1.41-2.26)], has not yet returned to work/school [OR, 2.48 (95% CI, 1.70-3.62)], chronic pain [OR, 1.63 (95% CI, 1.27-2.10)], and PTSD [OR, 2.23 (95% CI, 1.60-3.11)]. Similarly, low-income level was associated with not yet return to work/school [OR, 1.97 (95% CI, 1.09-3.56)], chronic pain [OR,1.70 (95% CI, 1.14-2.53)], and PTSD [OR, 2.20 (95% CI, 1.21-3.98)]. In sensitivity analyses, there were no significant differences in long-term outcomes between income levels.

Conclusion: Low educational level is strongly associated with worse long-term outcomes after injury. However, although household income is associated with long-term outcomes, it matters where the threshold is. The impact of different socioeconomic measures on long-term outcomes after trauma cannot be assumed to be interchangeable.

Level Of Evidence: Prognostic and epidemiological, level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002329DOI Listing
July 2019

Transferred Emergency General Surgery Patients Are at Increased Risk of Death: A NSQIP Propensity Score Matched Analysis.

J Am Coll Surg 2019 06 31;228(6):871-877. Epub 2019 Jan 31.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Background: Emergency general surgery (EGS) encompasses high-risk patients undergoing high-risk procedures. Admission source, particularly interhospital transfer, is rarely accounted for in clinical performance benchmarking. Our goal was to assess the impact of transfer status on outcomes after EGS.

Study Design: This was a retrospective analysis of the American College of Surgeons NSQIP database (2005 to 2014). All inpatients that underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally were included. Admission source was classified as directly admitted vs transferred from an outside emergency department or an acute care facility. The primary outcomes were overall mortality, overall morbidity, and major morbidity. A 3:1 propensity score matched analysis was used to determine the association of admission source with outcomes. Subgroup analysis was performed for high- and low-risk EGS procedures.

Results: A total of 222,519 EGS admissions were identified, of which 15,232 (6.8%) were transfers. Mean age was 46 years and 51.4% were female. Overall mortality was 3.1% for the entire cohort and 10.8% within the transfer group. After propensity score matched analysis for 33 clinical and demographic variables, transferred patients had higher rates of overall mortality (odds ratio 1.01; 95% CI 1.01 to 1.02), higher overall morbidity (odds ratio 1.07; 95% CI 1.05 to 1.09), and major morbidity (odds ratio 1.06; 95% CI 1.04 to 1.08) compared with directly admitted patients.

Conclusions: After rigorous risk adjustment, interhospital transfer status has a small effect on mortality and morbidity in the EGS population. This could suggest that it is reasonable to transfer patients and that regionalization of care should be encouraged.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2019.01.014DOI Listing
June 2019

Racial Differences in Complication Risk Following Emergency General Surgery: Who Your Surgeon Is May Matter.

J Surg Res 2019 03 16;235:424-431. Epub 2018 Nov 16.

Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts.

Background: Understanding the mechanisms that lead to health-care disparities is necessary to create robust solutions that ensure all patients receive the best possible care. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing an emergency general surgery (EGS).

Materials And Methods: Using the Florida State Inpatient Database, we analyzed patients who underwent one or more of seven EGS procedures from 2010 to 2014. The primary outcome was development of a major postoperative complication. To determine the individual surgeon effect on complications, we performed multilevel mixed effects modeling, adjusting for clinical and hospital factors, such as diagnosis, comorbidities, and hospital teaching status and volume.

Results: 215,745 cases performed by 5816 surgeons at 198 hospitals were included. The overall unadjusted complication rate was 8.6%. Black patients had a higher adjusted risk of having a complication than white patients (odds ratio 1.12, 95% confidence interval 1.03-1.22). Surgeon random effects, when hospital fixed effects were held constant, accounted for 27.2% of the unexplained variation in complication risk among surgeons. This effect was modified by patient race; for white patients, surgeon random effects explained only 12.4% of the variability, compared to 52.5% of the variability in complications among black patients.

Conclusions: This multiinstitution analysis within a single large state demonstrates that not only do black patients have a higher risk of developing a complication after undergoing EGS than white patients but also surgeon-level effects account for a larger proportion of the between-surgeon variation. This suggests that the individual surgeon contributes to racial disparities in EGS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.05.086DOI Listing
March 2019

The Future of Emergency General Surgery.

Ann Surg 2019 08;270(2):221-222

Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000003183DOI Listing
August 2019

Facilitating the Safe Diffusion of Surgical Innovations.

Ann Surg 2019 04;269(4):610-611

Department of Surgery, Brigham and Women's Hospital, Boston, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000003134DOI Listing
April 2019

Addressing the gap in clinical research education: Implementation of the Introduction to Clinical Research Training-Japan program.

J Gen Fam Med 2018 Nov 15;19(6):188-190. Epub 2018 Sep 15.

Division of Renal Medicine, Brigham and Women's Hospital Faculty Director for Global Education Postgraduate Medical Education Harvard Medical School Boston Massachusetts.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jgf2.204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238238PMC
November 2018

Failure to rescue and disparities in emergency general surgery.

J Surg Res 2018 11 9;231:62-68. Epub 2018 Jun 9.

Center for Surgery and Public Health (CSPH), One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts.

Background: Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events.

Methods: A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR).

Results: There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients.

Conclusions: Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.04.047DOI Listing
November 2018

Disparities in peptic ulcer disease: A nationwide study.

Am J Surg 2018 12 7;216(6):1127-1128. Epub 2018 Sep 7.

Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA.

Background: While advances in diagnosis and treatment of peptic ulcer disease have led to a decrease in hospital admissions the socioeconomic distribution of these benefits is unknown.

Methods: We designed a retrospective cohort study using the National Inpatient Sample from 2012 to 2013 including all patients that were admitted for peptic ulcer disease. We compared the types of ulcer related complications, the rates of intervention and the outcomes based on race and insurance status.

Results: Of 42,046 patients admitted for peptic ulcer disease 80.25% had an ulcer related complication. Black patients had the lowest rates of bleeding and highest rates of perforation and were less likely to undergo surgery for their complication but mortality was not different from white patients. Uninsured patients also had lower rates of bleeding and higher rates of perforation and they were at increased risk for death.

Conclusions: Unlike other surgical conditions insurance status, not race, predicts mortality in peptic ulcer disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2018.08.025DOI Listing
December 2018

Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call?

Surgery 2018 Nov 31;164(5):1109-1116. Epub 2018 Aug 31.

Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA; Department of Surgery, Brigham & Women's Hospital, Boston, MA.

Background: Hospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown.

Methods: We performed an analysis of the Florida State Inpatient Database (2010-2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived.

Results: Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes.

Conclusions: Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2018.07.008DOI Listing
November 2018

The impact of individual physicians on outcomes after trauma: is it the system or the surgeon?

J Surg Res 2018 09 16;229:51-57. Epub 2018 Apr 16.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma.

Methods: Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size.

Results: There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon.

Conclusions: At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.02.051DOI Listing
September 2018

An evidence-based intraoperative communication tool for emergency general surgery: a pilot study.

J Surg Res 2018 08 13;228:281-289. Epub 2018 Apr 13.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, Massachusetts; Ariadne Labs, Boston, Massachusetts.

Background: Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR).

Materials And Methods: We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis.

Results: Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation.

Conclusions: Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2018.03.007DOI Listing
August 2018

Past, present, and future of Emergency General Surgery in the USA.

Acute Med Surg 2018 04 12;5(2):119-122. Epub 2018 Jan 12.

Department of Surgery Brigham and Women's Hospital Boston MA.

Emergency General Surgery (EGS) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS. Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ams2.327DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5891107PMC
April 2018

Acute kidney injury predicts mortality in emergency general surgery patients.

Am J Surg 2018 09 14;216(3):420-426. Epub 2018 Mar 14.

The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Patients undergoing Emergency General Surgery (EGS) have increased risk of complications and death. The risk of AKI in patients undergoing EGS, along with associated outcomes, is unknown.

Methods: This two-institution observational study included adults admitted to intensive care units between 1997 and 2012. EGS was defined by 7 procedures occurring within 48 hours of ICU admission. The main outcome studied was AKI within 5 days, along with 90-day mortality.

Results: In our cohort of 59,604 patients, 1758 (2.9%) underwent EGS. Risk of AKI in EGD patients was significantly increased relative to non-EGS patients, with adjusted odds of 1.7 (95%CI 1.40-1.94; P < 0.001). Risk of renal replacement for EGS patients was also increased, with odds of 1.8 (95%CI 1.37-2.46; P < 0.001). EGS patients were at significantly higher risk of 90-day mortality, with adjusted odds of 3.1 (95%CI 2.16-4.33,p < 0.001) for AKI and 4.5 (95%CI 2.58-7.96,p < 0.001) for AKI requiring renal replacement, relative to the absence of AKI.

Conclusions: EGS is a robust risk factor for AKI in critically ill patients, the development of which is strongly predictive of increased 90-day mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2018.03.015DOI Listing
September 2018

Risk assessment in emergency general surgery.

J Trauma Acute Care Surg 2018 06;84(6):956-962

From the Division of Trauma, Critical Care, and General Surgery, Department of Surgery (M.H.), Mayo Clinic Rochester, Rochester, Minnesota; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery (J.H.), Brigham & Women's Hospital, Boston, Massachusetts; Baylor Scott & White Health System, Office of Chief Quality Officer (S.S.), Dallas, Texas; and Department of Surgery (M.C.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000001894DOI Listing
June 2018

The independent effect of emergency general surgery on outcomes varies depending on case type: A NSQIP outcomes study.

Am J Surg 2018 11 7;216(5):856-862. Epub 2018 Mar 7.

Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital Center for Surgery and Public Health, Boston, MA, USA. Electronic address:

Background: Emergency general surgery (EGS) is an independent risk factor for morbidity and mortality, and seven procedures account for 80% of the National burden of operative EGS. We aimed to characterize the excess morbidity and mortality attributable to these procedures based on the level of procedural risk.

Methods: Retrospective analysis of the ACS National Surgical Quality Improvement Project (ACS-NSQIP) database. (2005-2014). Seven EGS procedures were stratified as high risk and low risk. Primary outcomes were overall mortality, overall morbidity, major morbidity. Multivariable logistic regression was performed.

Results: There were 619,174 patients identified. Comparing EGS to non-EGS in high-risk cases the OR for overall mortality was 1.39(1.33,1.45), overall morbidity 1.07 (0.98, 1.16), and major morbidity 1.15(1.03,1,27). In low-risk cases the OR for overall mortality was 1.03 (0.89, 1.19) overall morbidity 1.35 (1.23, 1.48), and major morbidity 2.18(1.90, 2.50).

Conclusions: Using a Nationally representative clinical database we identified significant heterogeneity in the outcomes of EGS depending on procedural risk. Risk stratification and benchmarking strategies need to account for the inherent heterogeneity of EGS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2018.03.006DOI Listing
November 2018

Critical differences between elective and emergency surgery: identifying domains for quality improvement in emergency general surgery.

Surgery 2018 04 10;163(4):832-838. Epub 2018 Jan 10.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, MA.

Objective: The objective of our study was to characterize providers' impressions of factors contributing to disproportionate rates of morbidity and mortality in emergency general surgery to identify targets for care quality improvement.

Background: Emergency general surgery is characterized by a high-cost burden and disproportionate morbidity and mortality. Factors contributing to these observed disparities are not comprehensively understood and targets for quality improvement have not been formally developed.

Methods: Using a grounded theory approach, emergency general surgery providers were recruited through purposive-criterion-based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to emergency general surgery outcomes, to define effective care for EGS patients, and to describe operating room team structure. Interviews were performed to thematic saturation. Transcripts were iteratively coded and analyzed within and across cases to identify emergent themes. Member checking was performed to establish credibility of the findings.

Results: A total of 40 participants from 5 academic hospitals participated in either individual interviews (n = 25 [9 anesthesia, 12 surgery, 4 nursing]) or focus groups (n = 2 [15 nursing]). Emergency general surgery was characterized by an exceptionally high level of variability, which can be subcategorized as patient-variability (acute physiology and comorbidities) and system-variability (operating room resources and workforce). Multidisciplinary communication is identified as a modifier to variability in emergency general surgery; however, nursing is often left out of early communication exchanges.

Conclusion: Critical variability in emergency general surgery may impact outcomes. Patient-variability and system-variability, with focus on multidisciplinary communication, represent potential domains for quality improvement in this field.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2017.11.017DOI Listing
April 2018

Is there a "weekend effect" in emergency general surgery?

J Surg Res 2018 02;222:219-224

Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts.

Background: Weekend admission is associated with increased mortality across a range of patient populations and health-care systems. The aim of this study was to determine whether weekend admission is independently associated with serious adverse events (SAEs), in-hospital mortality, or failure to rescue (FTR) in emergency general surgery (EGS).

Methods: An observational study was performed using the National Inpatient Sample in 2012-2013; the largest all-payer inpatient database in the United States, which represents a 20% stratified sample of hospital discharges. The inclusion criteria were all inpatients with a primary EGS diagnosis. Outcomes were SAE, in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed an SAE). Multivariable logistic regression were used to adjust for patient- (age, sex, race, payer status, and Charlson comorbidity index) and hospital-level (trauma designation and hospital bed size) characteristics.

Results: There were 1,344,828 individual patient records (6.7 million weighted admissions). The overall rate of SAE was 15.1% (15.1% weekend, 14.9% weekday, P < 0.001), FTR 5.9% (6.2% weekend, 5.9% weekday, P = 0.010), and in-hospital mortality 1.4% (1.5% weekend, 1.3% weekday, P < 0.001). Within logistic regression models, weekend admission was an independent risk factor for development of SAE (adjusted odds ratio 1.08, 1.07-1.09), FTR (1.05, 1.01-1.10), and in-hospital mortality (1.14, 1.10-1.18).

Conclusions: This study found evidence that outcomes coded in an administrative data set are marginally worse for EGS patients admitted at weekends. This justifies further work using clinical data sets that can be used to better control for differences in case mix.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2017.10.019DOI Listing
February 2018

Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care.

J Trauma Acute Care Surg 2018 03;84(3):433-440

From the Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., T.C.T., P.U.N.); Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., A.H.H., A.S., J.M.H.); Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, UC Davis Health System, Sacramento, California (G.J.J., G.H.U.); and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., J.M.H.).

Background: Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality.

Methods: Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile.

Results: Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01).

Conclusions: Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes.

Level Of Evidence: Epidemiological, level III; Care management, level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000001768DOI Listing
March 2018

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes.

BMC Surg 2017 Dec 1;17(1):121. Epub 2017 Dec 1.

Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.

Background: Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda.

Methods: This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes.

Results: In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15-60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p < 0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p < 0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p < 0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died.

Conclusion: While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12893-017-0323-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709982PMC
December 2017