Publications by authors named "Kimberly A Davis"

153 Publications

Penetrating deep pelvic injury due to "less-lethal" beanbag munitions: a case report and policy implications.

Trauma Surg Acute Care Open 2021 10;6(1):e000754. Epub 2021 May 10.

Yale School of Medicine, New Haven, Connecticut, USA.

"Less-lethal" munitions are designed to cause incapacitation and are often used by law enforcement officers. Although these munitions are not designed to cause severe injury, recent reports have demonstrated that they can cause severe injury, permanent disability, and death. The long-term consequences of injury due to less-lethal munitions are not well understood. We present a case of osteomyelitis and pelvic abscess secondary to a retained beanbag munition following penetrating injury in the setting of a patient with delayed presentation for care. The patient underwent surgical removal of the retained beanbag munition and irrigation and debridement of the osteomyelitis and pelvic abscess with an excellent functional outcome. We discuss the public health and policy implications of serious injury due to less-lethal munitions.
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http://dx.doi.org/10.1136/tsaco-2021-000754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112415PMC
May 2021

Anticoagulation Is Associated with Increased Mortality in Splenic Injuries.

J Surg Res 2021 May 8;266:1-5. Epub 2021 May 8.

Division of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT.

Introduction: Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients.

Results: A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.
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http://dx.doi.org/10.1016/j.jss.2021.04.002DOI Listing
May 2021

Increased mortality with REBOA only mitigated by strong unmeasured confounding: an expanded analysis using the National Trauma Data Bank.

J Trauma Acute Care Surg 2021 May 5. Epub 2021 May 5.

Department of Surgery, Yale School of Medicine Applied Mathematics Program, Department of Mathematics, Yale University Department of Statistics and Data Science, Yale University.

REBOA is being increasingly adopted to manage non-compressible torso hemorrhage, but a recent analysis of the 2015-2016 Trauma Quality Improvement Project (TQIP) dataset showed that placement of REBOA was associated with higher rates of death, lower extremity amputation, and acute kidney injury (AKI). We expand this analysis by including the 2017 dataset, quantifying the potential role of residual confounding, and distinguishing between traumatic and ischemic lower extremity amputation.

Methods: This retrospective study used the 2015-2017 TQIP database and included patients older than 18 years old, with signs of life on arrival, no aortic injury, and were not transferred. REBOAs placed after 2 hours were excluded. We adjusted for baseline variables using propensity scores with inverse probability of treatment weighting (IPTW). A sensitivity analysis was then conducted to determine the strength of an unmeasured confounder (e.g. unmeasured shock severity/response to resuscitation) that could explain the effect on mortality. Finally, lower extremity injury patterns of patients undergoing REBOA were inspected to distinguish amputation indicated for traumatic injury from complications of REBOA placement.

Results: Of 1,392,482 patients meeting inclusion criteria, 187 underwent REBOA. After IPTW, all covariates were balanced. The risk difference for mortality was 0.21 (0.14 to 0.29) and for AKI was 0.041 (-0.007 to 0.089). For the mortality effect to be explained by an unmeasured confounder, it would need to be stronger than any observed in terms of its relationship with mortality and with REBOA placement. Eleven REBOA patients underwent lower extremity amputation, however they all suffered severe traumatic injury to the lower extremity.

Conclusion: There is no evidence in the TQIP dataset to suggest that REBOA causes amputation, and the evidence for its effect on AKI is considerably weaker than previously reported. The increased mortality effect of REBOA is confirmed and could only be nullified by a potent confounder.

Level Of Evidence: Level IV (Therapeutic/Care Management).
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http://dx.doi.org/10.1097/TA.0000000000003265DOI Listing
May 2021

Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes.

Ann Surg 2021 Feb 25. Epub 2021 Feb 25.

*Yale School of Medicine, New Haven, CT †Center for Surgery and Public Health: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA ‡Yale School of Public Health, New Haven, CT §Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom ¶The Aga Khan University Medical College, Karachi, Pakistan.

Objective: To critically evaluate whether admission at the beginning-versus-end of the academic year is associated with increased risk of major adverse outcomes.

Summary Background Data: The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989.

Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published prior to December 20, 2019, for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching-versus-non-teaching hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression.

Results: A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Meta-analyses of mortality (OR[95%CI]: 1.01[0.98-1.05]) and major morbidity (1.01[0.99-1.04]) demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions.

Conclusions: The preponderance of negative results over the past 30 years suggests that it may be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000004805DOI Listing
February 2021

Sex-based differences in helmet performance in bicycle trauma.

J Epidemiol Community Health 2021 Apr 7. Epub 2021 Apr 7.

Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA

Objectives: To determine the existence of sex-based differences in the protective effects of helmets against common injuries in bicycle trauma.

Methods: In a retrospective cohort study, we identified patients 18 years or older in the 2017 National Trauma Database presenting after bicycle crash. Sex-disaggregated and sex-combined multivariable logistic regression models were calculated for short-term outcomes that included age, involvement with motor vehicle collision, anticoagulant use, bleeding disorder and helmet use. The sex-combined model included an interaction term for sex and helmet use. The resulting exponentiated model parameter yields an adjusted OR ratio of the effects of helmet use for females compared with males.

Results: In total, 18 604 patients of average age 48.1 were identified, and 18% were female. Helmet use was greater in females than males (48.0% vs 34.2%, p<0.001). Compared with helmeted males, helmeted females had greater rates of serious head injury (37.7% vs 29.9%, p<0.001) despite less injury overall. In sex-disaggregated models, helmet use reduced odds of intracranial haemorrhage and death in males (p<0.001) but not females. In sex-combined models, helmets conferred to females significantly less odds reduction for severe head injury (p=0.002), intracranial bleeding (p<0.001), skull fractures (p=0.001), cranial surgery (p=0.006) and death (p=0.017). There was no difference for cervical spine fracture.

Conclusions: Bicycle helmets may offer less protection to females compared with males. The cause of this sex or gender-based difference is uncertain, but there may be intrinsic incompatibility between available helmets and female anatomy and/or sex disparity in helmet testing standards.
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http://dx.doi.org/10.1136/jech-2020-215544DOI Listing
April 2021

Tricuspid bullet embolism: lessons learnt from a rare firearm sequelae.

Trauma Surg Acute Care Open 2021 25;6(1):e000657. Epub 2021 Feb 25.

General Surgery, Trauma & Surgical Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA.

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http://dx.doi.org/10.1136/tsaco-2020-000657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908904PMC
February 2021

Learning from England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes.

Ann Surg 2021 Jan 22. Epub 2021 Jan 22.

Yale School of Medicine, New Haven, CT Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom Center for Surgery and Public Health: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA Yale School of Public Health, New Haven, CT Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, MA.

Objective: The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan.

Summary Background Data: Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative.

Methods: Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000-2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65y) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved.

Results: 806,036 English and 3,221,109 US hospitalizations were included. Following BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000-2016, US outcomes were stagnant (p > 0.05), resulting in an inversion of the countries' mortality and > 38,000 potential annual US lives saved.

Conclusions: Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.
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http://dx.doi.org/10.1097/SLA.0000000000004305DOI Listing
January 2021

Choosing the Best Approach to Warfarin Reversal After Traumatic Intracranial Hemorrhage.

J Surg Res 2021 Apr 31;260:369-376. Epub 2020 Dec 31.

Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut. Electronic address:

Background: Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH).

Materials And Methods: This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents.

Results: Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001).

Conclusions: Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.
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http://dx.doi.org/10.1016/j.jss.2020.12.004DOI Listing
April 2021

Urgent Care Centers Delay Emergent Surgical Care Based on Patient Insurance Status in The United States.

Ann Surg 2020 10;272(4):548-553

Department of Surgery, Division of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, CT.

Objective: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition.

Methods: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types.

Results: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29).

Conclusions: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.
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http://dx.doi.org/10.1097/SLA.0000000000004373DOI Listing
October 2020

Hospital Volume and Operative Mortality for General Surgery Operations Performed Emergently in Adults.

Ann Surg 2020 08;272(2):288-303

Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT.

Objective: This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk?

Background: Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies.

Methods: Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality.

Results: A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair.

Conclusions: Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.
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http://dx.doi.org/10.1097/SLA.0000000000003232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6803029PMC
August 2020

Geographic Variation in the Utilization of and Mortality After Emergency General Surgery Operations in the Northeastern and Southeastern United States.

Ann Surg 2020 Jun 9. Epub 2020 Jun 9.

Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, Yale School of Public Health, New Haven, CT.

Objective: To define geographic variations in emergency general surgery (EGS) care, we sought to determine how much variability exists in the rates of EGS operations and subsequent mortality in the Northeastern and Southeastern United States (US).

Summary Background Data: While some geographic variations in healthcare are normal, unwarranted variations raise questions about the quality, appropriateness, and cost-effectiveness of care in different areas.

Methods: Patients ≥18 years who underwent 1 of 10 common EGS operations were identified using the State Inpatient Databases (2011-2012) for 6 states, representing Northeastern (New York) and Southeastern (Florida, Georgia, Kentucky, North Carolina, Mississippi) US. Geographic unit of analysis was the hospital service area (HSA). Age-standardized rates of operations and in-hospital mortality were calculated and mapped. Differences in rates across geographic areas were compared using the Kruskal-Wallis test, and variance quantified using linear random-effects models. Variation profiles were tabulated via standardized rates of utilization and mortality to compare geographically heterogenous areas.

Results: 227,109 EGS operations were geospatially analyzed across the 6 states. Age-standardized EGS operation rates varied significantly by region (Northeast rate of 22.7 EGS operations per 10,000 in population versus Southeast 21.9; P < 0.001), state (ranging from 9.9 to 29.1; P < 0.001), and HSA (1.9-56.7; P < 0.001). The geographic variability in age-standardized EGS mortality rates was also significant at the region level (Northeast mortality rate 7.2 per 1000 operations vs Southeast 7.4; P < 0.001), state-level (ranging from 5.9 to 9.0 deaths per 1000 EGS operations; P < 0.001), and HSA-level (0.0-77.3; P < 0.001). Maps and variation profiles visually exhibited widespread and substantial differences in EGS use and morality.

Conclusions: Wide geographic variations exist across 6 Northeastern and Southeastern US states in the rates of EGS operations and subsequent mortality. More detailed geographic analyses are needed to determine the basis of these variations and how they can be minimized.
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http://dx.doi.org/10.1097/SLA.0000000000003939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726051PMC
June 2020

The effect of anticoagulation on outcomes after liver and spleen injuries: A research consortium of New England centers for trauma (ReCONECT) study.

Injury 2020 Sep 15;51(9):1994-1998. Epub 2020 May 15.

Yale School of Medicine, New Haven, CT, United States.

Background: Liver and spleen injuries are the most commonly injured solid organs, the effects of anticoagulation on these injuries has not yet been well characterized.

Study Design: Multicenter retrospective study.

Result: During the 4-year study period, 1254 patients, 64 (5%) on anticoagulation (AC), were admitted with liver and/or splenic injury. 58% of patients had a splenic injury, 53% had a liver injury and 11% had both. Patients on AC were older than non-AC patients (mean age 60.9 vs. 38.6 years, p < 0.001). The most common AC drug was warfarin (70%) with atrial fibrillation (47%) the most common indication for AC. There was no significant difference in AAST injury grade between AC and non-AC patients (median grade 2), but AC patients required a blood product transfusion more commonly (58 vs 40%, p = 0.007) particularly FFP (4 vs 19%, p < 0.01). Among those transfused, non-AC patients required slightly more PRBC (5.7 vs 3.8 units, p = 0.018) but similar amount of FFP (3.2 vs 3.1 units, p = 0.92). The two groups had no significant difference in the rates of initial non-operative management (50% (AC) vs 56% (non-AC), p = 0.3)) or failure of non-operative management (7 vs 4%, p = 0.16). AC patients were more likely to be managed initially with angiography (36 vs 20%, p = 0.001) while non-AC patients with surgery (24% vs 13%, p = 0.04). There was no significant difference in LOS and mortality.

Conclusion: The use of anticoagulation did not result in a difference in outcomes among patients with spleen and/or liver injuries.
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http://dx.doi.org/10.1016/j.injury.2020.05.002DOI Listing
September 2020

Current opinion on emergency general surgery transfer and triage criteria.

J Trauma Acute Care Surg 2020 09;89(3):e71-e77

From the Division of General Surgery (M.L.M.), University of Utah, Salt Lake City, Utah; Division of General Surgery, Trauma and Surgical Critical Care (K.A.D.), Yale School of Medicine, New Haven, Connecticut; Division of Trauma, Emergency Surgery and Surgical Critical Care (H.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Critical Care and Burn, Wexner Medical Center (H.S.), The Ohio State University, Columbus, Ohio; Surgical Group of North Texas (S.S.), Dallas, Texas; Division of Acute Care Surgery (M.C.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida.

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http://dx.doi.org/10.1097/TA.0000000000002806DOI Listing
September 2020

Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures.

J Trauma Acute Care Surg 2020 11;89(5):947-954

From the Department of Surgery, Yale School of Medicine, New Haven, Connecticut.

Background: Geriatric patients with rib fractures are at risk for developing complications and are often admitted to a higher level of care (intensive care units [ICUs]) based on existing guidelines. Forced vital capacity (FVC) has been shown to correlate with outcomes in patients with rib fractures. Complete spirometry may quantify pulmonary capacity, predict outcome, and potentially assist with admission triage decisions.

Methods: We prospectively enrolled 86 patients, 60 years or older with three or more isolated rib fractures presenting after injury. After informed consent, patients were assessed with respect to pain (visual analog scale), grip strength, FVC, forced expiratory volume 1 second (FEV1), and negative inspiratory force on hospital days 1, 2, and 3. Outcomes included discharge disposition, length of stay (LOS), pneumonia, intubation, and unplanned ICU admission.

Results: Mean age was 77.4 (SD, 10.2) and 43 (50.0%) were female. Forty-five patients (55.6%) were discharged home, median LOS was 4 days (interquartile range, 3-7). Pneumonias (2), unplanned ICU admissions (3), and intubation (1) were infrequent. Spirometry measures including FVC, FEV1, and grip strength predicted discharge to home and FEV1, and pain level on day 1 moderately correlated with the LOS. Within each subject, FVC, FEV1, and negative inspiratory force did not change for 3 days despite pain at rest and pain after spirometry improving from day 1 to 3 (p = 0.002, p < 0.001 respectively). Change in pain also did not predict outcomes and pain level was not associated with respiratory volumes on any of the 3 days. After adjustment for confounders, FEV1 remained a significant predictor of discharge home (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and LOS (p = 0.001).

Conclusion: Spirometry measurements early in the hospital stay predict ultimate discharge home, and this may allow immediate or early discharge. The impact of pain control on pulmonary function requires further study.

Level Of Evidence: Diagnostic test, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002795DOI Listing
November 2020

Out of Darkness.

Ann Surg 2020 09;272(3):e211-e212

Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1097/SLA.0000000000004108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467052PMC
September 2020

Tube thoracostomy during the COVID-19 pandemic: guidance and recommendations from the AAST Acute Care Surgery and Critical Care Committees.

Trauma Surg Acute Care Open 2020 30;5(1):e000498. Epub 2020 Apr 30.

Department of Surgery, Inova Fairfax Medical Center, Falls Church, Virginia, USA.

This document provides guidance for trauma and acute care surgeons surrounding the placement, management and removal of chest tubes during the COVID-19 pandemic.
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http://dx.doi.org/10.1136/tsaco-2020-000498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213907PMC
April 2020

Mapping the increasing interest in acute care surgery-Who, why and which fellowship?

J Trauma Acute Care Surg 2020 05;88(5):629-635

From Spectrum Health (B.N.G.), Grand Rapids, Michigan; University of Wisconsin (B.L.Z.), Madison, Wisconsin; Rutgers University (D.H.L.), Camden, New Jersey; University of Maryland (W.C.C., S.A.T.), College Park, Maryland; Yale University (K.A.D.), New Haven, Connecticut; University of Michigan (H.B.A.), Ann Arbor, Michigan; and Stanford University (D.A.S.), Stanford, California.

Background: Interest in acute care surgery (ACS) has increased over the past 10 years as demonstrated by the linear increase in fellowship applicants to the different fellowships leading to ACS careers. It is unclear why interest has increased, whether various fellowship pathways attract different applicants or whether fellowship choice correlates with practice patterns after graduation.

Methods: An online survey was distributed to individuals previously registered with the Surgical critical care and Acute care surgery Fellowship Application Service. Fellowship program directors were also asked to forward the survey to current and former fellows to increase the response rate. Data collected included demographics, clinical interests and motivations, publications, and postfellowship practice patterns. Fisher's exact and Pearson's χ were used to determine significance.

Results: Trauma surgery was the primary clinical interest for all fellowship types (n = 273). Fellowship type had no impact on academic productivity or practice patterns. Most fellows would repeat their own fellowship. The 2-year American Association for the Surgery of Trauma-approved fellowship was nearly uniformly reported as the preferred choice among those who would perform a different fellowship. Career motivations were similar across fellowships and over time though recent trainees were more likely to consider predictability of schedule a significant factor in career choice. Respondents reported graduated progression to full responsibility, further exposure to trauma care and additional operative technical training as benefits of a second fellowship year.

Conclusion: American Association for the Surgery of Trauma-approved 2-year fellows appear to be the most satisfied with their fellowship choice. No differences were noted in academic productivity or practice between fellowships. Future research should focus on variability in trauma training and operative experience during residency and in practice to better inform how a second fellowship year would improve training for ACS careers.

Level Of Evidence: Descriptive, mixed methods, Level IV.
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http://dx.doi.org/10.1097/TA.0000000000002585DOI Listing
May 2020

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume.

J Trauma Acute Care Surg 2020 05;88(5):619-628

From the Department of Surgery (C.K.Z., K.A.D.), Yale School of Medicine, New Haven, Connecticut; Center for Surgery and Public Health, Department of Surgery (C.K.Z., S.A.H.), Brigham & Women's Hospital, Harvard Medical School; Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Surgery (A.C.B.), College of Medicine, University of Kentucky, Lexington, Kentucky; Department of Surgery (J.P.M.), University of Texas Southwestern Medical Center, Dallas, Texas; and Department of Surgery (K.L.S.), Stanford School of Medicine, Stanford, California.

Background: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC).

Methods: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume.

Results: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million).

Conclusion: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value.

Level Of Evidence: Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802807PMC
May 2020

Hospital Variation in Geriatric Surgical Safety for Emergency Operation.

J Am Coll Surg 2020 06 4;230(6):966-973.e10. Epub 2020 Feb 4.

Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.

Background: The American College of Surgeons maintains that surgical care in the US has not reached optimal safety and quality. This can be driven partially by higher-risk, emergency operations in geriatric patients. We therefore sought to answer 2 questions: First, to what degree does standardized postoperative mortality vary in hospitals performing nonelective operations in geriatric patients? Second, can the differences in hospital-based mortality be explained by patient-, operative-, and hospital-level characteristics among outlier institutions?

Study Design: Patients 65 years and older who underwent 1 of 8 common emergency general surgery operations were identified using the California State Inpatient Database (2010 to 2011). Expected mortality was obtained from hierarchical, Bayesian mixed-effects logistic regression models. A risk-adjusted hospital-level standardized mortality ratio (SMR) was calculated from observed-to-expected in-hospital deaths. "Outlier" hospitals had an SMR 80% CI that did not cross the mean SMR of 1.0. High-mortality (SMR >1.0) and low-mortality (SMR <1.0) outliers were compared.

Results: We included 24,207 patients from 107 hospitals. SMRs varied widely, from 2.3 (highest) to 0.3 (lowest). Eleven hospitals (10.3%) were poor-performing high-SMR outliers, and 10 hospitals (9.3%) were exceptional-performing low-SMR outliers. SMR was 3 times worse in the high-SMR compared with the low-SMR group (1.7 vs 0.6; p < 0.001). Patient-, operation-, and hospital-level characteristics were equivalent among outlier-hospitals.

Conclusions: Significant hospital variation exists in standardized mortality after common general surgery operations done emergently in older patients. More than 10% of institutions have substantial excess mortality. These findings confirm that the safety of emergency operation in geriatric patients can be significantly improved by decreasing the wide variability in mortality outcomes.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.10.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409563PMC
June 2020

Regionalization of emergency general surgery operations: A simulation study.

J Trauma Acute Care Surg 2020 03;88(3):366-371

From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (R.D.B., M.P.D., A.A.M., K.M.S., K.A.D.), Yale School of Medicine; Yale Center for Analytical Sciences (N.S., M.J.S.), Yale School of Public Health; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut.

Background: It has been theorized that a tiered, regionalized system of care for emergency general surgery (EGS) patients-akin to regional trauma systems-would translate into significant survival benefits. Yet data to support this supposition are lacking. The aim of this study was to determine the potential number of lives that could be saved by regionalizing EGS care to higher-volume, lower-mortality EGS institutions.

Methods: Adult patients who underwent one of 10 common EGS operations were identified in the California Inpatient Database (2010-2011). An algorithm was constructed that "closed" lower-volume, higher-mortality hospitals and referred those patients to higher-volume, lower-mortality institutions ("closure" based on hospital EGS volume-threshold that optimized to 95% probability of survival). Primary outcome was the number of lives saved. Fifty thousand regionalization simulations were completed (5,000 for each operation) employing a bootstrap resampling method to proportionally redistribute patients. Estimates of expected deaths at the higher-volume hospitals were recalculated for every bootstrapped sample.

Results: Of the 165,123 patients who underwent EGS operations over the 2-year period, 17,655 (10.7%) were regionalized to a higher-volume hospital. On average, 128 (48.8%) of lower-volume hospitals were "closed," ranging from 68 (22.0%) hospital closures for appendectomy to 205 (73.2%) for small bowel resection. The simulations demonstrated that EGS regionalization would prevent 9.7% of risk-adjusted EGS deaths, significantly saving lives for every EGS operation: from 30.8 (6.5%) deaths prevented for appendectomy to 122.8 (7.9%) for colectomy. Regionalization prevented 4.6 deaths per 100 EGS patient-transfers, ranging from 1.3 for appendectomy to 8.0 for umbilical hernia repair.

Conclusion: This simulation study provides important new insight into the concept of EGS regionalization, suggesting that 1 in 10 risk-adjusted deaths could be prevented by a structured system of EGS care. Future work should expand upon these findings using more complex discrete-event simulation models.

Level Of Evidence: Therapeutic/Care Management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7472889PMC
March 2020

Top-tier emergency general surgery hospitals: Good at one operation, good at them all.

J Trauma Acute Care Surg 2019 08;87(2):289-296

From the Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (M.P.D., A.A.M., K.M.S., K.A.D., R.D.B.), Yale School of Medicine, New Haven, Connecticut; Yale Center for Analytical Sciences, Yale School of Public Health (N.S., M.J.S.), New Haven, Connecticut; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut.

Background: There is a longstanding interest in the field of management science to study high performance organizations. Applied to medicine, research on hospital performance indicates that some hospitals are high performing, while others are not. The objective of this study was to identify a cluster of high-performing emergency general surgery (EGS) hospitals and assess whether high performance at one EGS operation was associated with high performance on all EGS operations.

Methods: Adult patients who underwent one of eight EGS operations were identified in the California State Inpatient Database (2010-2011), which we linked to the American Hospital Association database. Beta regression was used to estimate a hospital's risk-adjusted mortality, accounting for patient- and hospital-level factors. Centroid cluster analysis grouped hospitals by patterns of mortality rates across the eight EGS operations using z scores. Multinomial logistic regression compared hospital characteristics by cluster.

Results: A total of 220 acute care hospitals were included. Three distinct clusters of hospitals were defined based on assessment of mortality for each operation type: high-performing hospitals (n = 66), average performing (n = 99), and low performing (n = 55). The mortality by individual operation type at the high-performing cluster was consistently at least 1.5 standard deviations better than the low-performing cluster (p < 0.001). Within-cluster variation was minimal at high-performing hospitals compared with wide variation at low-performing hospitals. A hospital's high performance in one EGS operation type predicted high performance on all EGS operation types.

Conclusion: High-performing EGS hospitals attain excellence across all types of EGS operations, with minimal variability in mortality. Poor-performing hospitals are persistently below average, even for low-risk operations. These findings suggest that top-performing EGS hospitals are highly reliable, with systems of care in place to achieve consistently superior results. Further investigation and collaboration are needed to identify the factors associated with high performance.

Level Of Evidence: Prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000002367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6771423PMC
August 2019

High-performance acute care hospitals: Excelling across multiple emergency general surgery operations in the geriatric patient.

J Trauma Acute Care Surg 2019 07;87(1):140-146

From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (M.P.D., A.A.M., K.M.S., K.A.D., R.D.B.), Yale School of Medicine; Yale Center for Analytical Sciences (N.S., M.J.S.), Yale School of Public Health; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut.

Background: As the geriatric population grows, the need for hospitals performing high quality emergency general surgery (EGS) on older patients will increase. Identifying clusters of high-performing geriatric emergency general surgery hospitals would substantiate the need for in-depth analyses of hospital-specific structures and practices that benefit older EGS patients. The objectives of this study were therefore to identify clusters of hospitals based on mortality performance for geriatric patients undergoing common EGS operations and to determine if hospital performance was similar for all operation types.

Methods: Hospitals in the California State Inpatient Database were included if they performed a range of eight common EGS operations in patients 65 years or older, with a minimum requirement of three of each operation performed over 2 years. Multivariable beta regression models were created to define hospital-level risk-adjusted mortality. Centroid cluster analysis was used to identify groups of hospitals based on mortality and to determine if mortality-performance differed by operation.

Results: One hundred seven hospitals were included, performing a total of 24,279 operations in older patients. Hospitals separated into three distinct clusters: high, average, and low performers. The high-performing hospitals had survival rates 1 to 2 standard deviations better than the low-performers (p < 0.001). For each cluster, high performance in any one EGS operation consistently translated into high performance across all EGS operations.

Conclusion: Hospitals conducting EGS operations in the geriatric patient population cluster into three distinct groups based on their survival performance. High-performing hospitals significantly outperform the average and low performers across every operation. The high-performers achieve reliable, high-quality results regardless of operation type. Further qualitative research is needed to investigate the perioperative drivers of hospital performance in the geriatric EGS population.

Level Of Evidence: Study Type Prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000002273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656193PMC
July 2019

Step-up approach for the management of pancreatic necrosis: a review of the literature.

Trauma Surg Acute Care Open 2019 19;4(1):e000308. Epub 2019 May 19.

Surgery, Yale School of Medicine, New Haven, Connecticut, USA.

Infected necrotizing pancreatitis is a challenging condition to treat because of the profound inflammatory response these patients undergo which can then be exacerbated by interventions. Treatment of this condition has evolved in timing of intervention as well as method of intervention and includes less invasive options for treatment such as percutaneous drainage and endoscopic drainage, in addition to less invasive endoscopic and video-assisted or laparoscopic debridements. The precise optimal treatment strategy for these patients is an ongoing topic of discussion and may be different for each patient as this is a heterogenous condition.
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http://dx.doi.org/10.1136/tsaco-2019-000308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560663PMC
May 2019

Rethinking our definition of operative success: predicting early mortality after emergency general surgery colon resection.

Trauma Surg Acute Care Open 2019 15;4(1):e000244. Epub 2019 May 15.

Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA.

Background: The postoperative outcomes of emergency general surgery patients can be fraught with uncertainty. Although surgical risk calculators exist to predict 30-day mortality, they are often of limited utility in preparing patients and families for immediate perioperative complications. Examination of trends in mortality after emergent colectomy may help inform complex perioperative decision-making. We hypothesized that risk factors could be identified to predict early mortality (before postoperative day 5) to inform operative decisions.

Methods: This analysis was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2014). Patients were stratified into three groups: early death (postoperative day 0-4), late death (postoperative day 5-30), and those who survived. Multivariable logistic regression was used to explore characteristics associated with early death. Kaplan-Meier models and Cox regression were used to further characterize their impact.

Results: A total of 18 803 patients were analyzed. Overall 30-day mortality was 12.5% (3316); of these, 37.1% (899) were early deaths. The preoperative factors most predictive of early death were septic shock (OR 3.62, p<0.001), ventilator dependence (OR 2.81, p<0.001), and ascites (OR 1.63, p<0.001). Postoperative complications associated with early death included pulmonary embolism (OR 5.78, p<0.001), presence of new-onset or ongoing postoperative septic shock (OR 4.45, p<0.001) and new-onset renal failure (OR 1.89, p<0.001). Patients with both preoperative and postoperative shock had an overall mortality rate of 47% with over half of all deaths occurring in the early period.

Conclusions: Nearly 40% of patients who die after emergent colon resection do so before postoperative day 5. Early mortality is heavily influenced by the presence of both preoperative and new or persistent postoperative septic shock. These results demonstrate important temporal trends of mortality, which may inform perioperative patient and family discussions and complex management decisions.

Level Of Evidence: Level III. Study type: Prognostic.
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http://dx.doi.org/10.1136/tsaco-2018-000244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560481PMC
May 2019

Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas.

Am J Surg 2020 04 14;219(4):707-710. Epub 2019 May 14.

Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.

Background: Retroperitoneal and rectus sheath hematomas can occur spontaneously. There is a lack of research about the disease progression, optimal treatment strategies and the need for surgical intervention. Our study investigated their outcomes and management.

Study Design: Adult patients admitted during a one-year period with non-traumatic retroperitoneal or rectus sheath hematomas were retrospectively identified. Biographical, hospital-course, and outcome data were extracted.

Results: 99 patients were included; median age was 73-years (IQR 61-80). 88 patients were on an anticoagulant or antiplatelet agent. Warfarin and intravenous heparin being the most commonly utilized agents (42% and 36.4%, respectively). All 99 patients were diagnosed by CT scan. 79 patients received some sort of blood product (79.8% PRBC, 43.4% FFP, 17% platelets), and 26 patients were in hemorrhagic shock. 17 patients underwent angiography and/or angioembolization. Neither anticoagulation in general nor any specific agent was associated with the need for blood product transfusion or angiography. 13 patients died but none were attributable to the hematoma.

Conclusion: Both hematomas are usually self-limiting and rarely require surgical intervention. A subset may require angioembolization.
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http://dx.doi.org/10.1016/j.amjsurg.2019.05.002DOI Listing
April 2020

Macroeconomic trends and practice models impacting acute care surgery.

Trauma Surg Acute Care Open 2019 11;4(1):e000295. Epub 2019 Apr 11.

Surgery, Yale School of Medicine, New Haven, Connecticut, USA.

Acute care surgery (ACS) diagnoses are responsible for approximately a quarter of the costs of inpatient care in the US government, and individuals will be responsible for a larger share of the costs of this healthcare as the population ages. ACS as a specialty thus has the opportunity to meet a significant healthcare need, and by optimizing care delivery models do so in a way that improves both quality and value. ACS practice models that have maintained or added emergency general surgery (EGS) and even elective surgery have realized more operative case volume and surgeon satisfaction. However, vulnerabilities exist in the ACS model. Payer mix in a practice varies by geography and distribution of EGS, trauma, critical care, and elective surgery. Critical care codes constitute approximately 25% of all billing by acute care surgeons, so even small changes in reimbursement in critical care can have significant impact on professional revenue. Staffing an ACS practice can be challenging depending on reimbursement and due to uneven geographic distribution of available surgeons. Empowered by an understanding of economics, using team-oriented leadership inherent to trauma surgeons, and in partnership with healthcare organizations and regulatory bodies, ACS surgeons are positioned to significantly influence the future of healthcare in the USA.
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http://dx.doi.org/10.1136/tsaco-2018-000295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6461137PMC
April 2019

The current and future economic state of acute care surgery.

J Trauma Acute Care Surg 2019 Aug;87(2):413-419

From the Stanford University (K.S.), Stanford, California; University of Kentucky College of Medicine (A.B.), Lexington, Kentucky; Yale School of Medicine (K.A.D.), New Haven, Connecticut; University of California, San Diego (J.D.), San Diego, California; Aga Khan University Medical College (A.H.), Karachi, Pakistan (L.R.T.S.); University of Texas Southwestern Medical School (J.P.M.), Dallas, Texas.

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http://dx.doi.org/10.1097/TA.0000000000002334DOI Listing
August 2019

Hospital Operative Volume as a Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients

J Am Coll Surg 2019 06 18;228(6):910-923. Epub 2019 Apr 18.

Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT.

Background: Within the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes can require a structured system of surgical care based on key quality indicators. To investigate this, the current study sought to answer 2 questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume will geriatric patients undergoing an emergency operation achieve at or better than average mortality risk?

Study Design: Retrospective cohort study of geriatric patients (aged 65 years and older) who underwent 1 of 10 EGS operations identified from the California State Inpatient Database (2010 to 2011). β-Logistic generalized linear regression was used, with the hospital as the unit of analysis, to investigate the relationship between hospital operative volume and in-hospital riskv-adjusted mortality. Hospital operative volume thresholds to optimize probability of survival were defined.

Results: There were 41,860 operations evaluated at 299 hospitals. For each operation, mortality decreased as hospital emergency operative volume increased (p < 0.001 for each operation); for every standardized increase in volume (meaning +1 natural logarithm of volume), the reduction in mortality ranged from 14% for colectomy to 61% for appendectomy. Hospital volume thresholds, which optimize to 95% probability of survival, varied by procedure, with a mean of 14 operations over 2 years. More than 50% of hospitals did not meet the threshold benchmarks, representing 22% of patients.

Conclusions: Survival rates for geriatric patients were improved substantially when emergency operations were performed at hospitals with higher operative volumes. Consistent with all active Quality Programs of the American College of Surgeons, hospital operative volume appears to be an important metric of surgical quality for older patients undergoing emergency operations.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.02.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582986PMC
June 2019

Evaluating mortality outlier hospitals to improve the quality of care in emergency general surgery.

J Trauma Acute Care Surg 2019 08;87(2):297-306

From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (R.D.B., M.P.D., A.A.M., K.M.S., K.A.D.), Yale School of Medicine; Yale Center for Analytical Sciences (N.S., M.J.S.), Yale School of Public Health; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut.

Background: Expected performance rates for various outcome metrics are a hallmark of hospital quality indicators used by Agency of Healthcare Research and Quality, Center for Medicare and Medicaid Services, and National Quality Forum. The identification of outlier hospitals with above- and below-expected mortality for emergency general surgery (EGS) operations is therefore of great value for EGS quality improvement initiatives. The aim of this study was to determine hospital variation in mortality after EGS operations, and compare characteristics between outlier hospitals.

Methods: Using data from the California State Inpatient Database (2010-2011), we identified patients who underwent one of eight common EGS operations. Expected mortality was obtained from a Bayesian model, adjusting for both patient- and hospital-level variables. A hospital-level standardized mortality ratio (SMR) was constructed (ratio of observed to expected deaths). Only hospitals performing three or more of each operation were included. An "outlier" hospital was defined as having an SMR with 80% confidence interval that did not cross 1.0. High- and low-mortality SMR outliers were compared.

Results: There were 140,333 patients included from 220 hospitals. Standardized mortality ratio varied from a high of 2.6 (mortality, 160% higher than expected) to a low of 0.2 (mortality, 80% lower than expected); 12 hospitals were high SMR outliers, and 28 were low SMR outliers. Standardized mortality was over three times worse in the high SMR outliers compared with the low SMR outliers (1.7 vs. 0.5; p < 0.001). Hospital-, patient-, and operative-level characteristics were equivalent in each outlier group.

Conclusion: There exists significant hospital variation in standardized mortality after EGS operations. High SMR outliers have significant excess mortality, while low SMR outliers have superior EGS survival. Common hospital-level characteristics do not explain the wide gap between underperforming and overperforming outlier institutions. These findings suggest that SMR can help guide assessment of EGS performance across hospitals; further research is essential to identify and define the hospital processes of care which translate into optimal EGS outcomes.

Level Of Evidence: Epidemiologic Study, level III.
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http://dx.doi.org/10.1097/TA.0000000000002271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660354PMC
August 2019