Greater cost without greater benefit: The need to refine transfer criteria for patients with severe acute pancreatitis.

BACKGROUND: Appropriate and timely care is essential in the management of severe acute pancreatitis (SAP). We hypothesized that transferred patients with SAP undergoing procedural intervention would have higher mortality compared to those managed directly at academic centers. METHODS: This was a retrospective analysis of Maryland's statewide claims database from 2009 to 2022 of adult patients admitted with a primary diagnosis of SAP (acute pancreatitis with organ failure). Patients were divided into three groups: those admitted directly from the emergency room to academic facilities (AD), non-academic facilities (NA), or transferred to academic facilities (TR). Procedural intervention included endoscopic, percutaneous image-guided, or surgical. The primary outcome was in-hospital mortality. Secondary outcomes were admission costs, length of stay (LOS), and intensive care unit (ICU) admission. RESULTS: There were 7,648 (48.9%) in the NA group, 6,682 (42.7%) in the AD group and 1,316 (8.4%) in the TR group. On regression analysis, odds of death were 0.57x lower in the NA group and 0.67x lower in the AD group compared to transfers (<0.001). Procedural intervention was not associated with increased mortality. Transferred patients had longer median LOS (11 vs NA = 5, AD = 6, p < 0.001), increased median cost of admission ($41k vs NA = $12k, AD = $17k, p < 0.001) and greater ICU admission (45.6% vs NA = 20.6%, AD = 23.9%, p < 0.001). CONCLUSION: Transferred patients have greater burden of illness and cost of care without evidence of improved outcomes in the management of SAP regardless of procedural intervention. Transfer criteria for patients with SAP must be further refined to reduce unnecessary transfers.

Cost Differences Between Teaching and Nonteaching Hospitals for Older Adults Requiring Emergency General Surgery Procedures in the State of Maryland.

BACKGROUND: Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs). METHODS: A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality. RESULTS: Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, P<.001) compared to NTHs. Lysis of adhesions, cholecystectomy, and PC comprised the overall most common EGSPs. Older adults at THs incurred comparatively higher median hospital charges for every EGSP due to increased room charges and LOS. Mortality was higher at THs (6.13% vs 5.33%, P<.001). CONCLUSION: While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease.

BACKGROUND: Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers. METHODS: Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression. RESULTS: Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality. CONCLUSIONS: Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.

Emergency pediatric surgery: Comparing the economic burden in specialized versus nonspecialized children's centers.

BACKGROUND: The American College of Surgeons has developed a verification program for children's surgery centers. Highly specialized hospitals may be verified as Level I, while those with fewer dedicated resources as Level II or Level III, respectively. We hypothesized that more specialized children's centers would utilize more resources. STUDY DESIGN: We performed a retrospective study of the Maryland Health Services Cost Review Commission (HSCRC) database from 2009 to 2013. We assessed total charge, length of stay (LOS), and charge per day for all inpatients with an emergency pediatric surgery diagnosis, controlling for severity of illness (SOI). Using published resources, we assigned theoretical level designations to each hospital. RESULTS: Two hospitals would qualify as Level 1 hospitals, with 4593 total emergency pediatric surgery admissions (38.5%) over the five-year study period. Charges were significantly higher for children treated at Level I hospitals (all P<0.0001). Across all SOI, children at Level I hospitals had significantly longer LOS (all P<0.0001). CONCLUSION: Hospitals defined as Level II and Level III provided the majority of care and were able to do so with shorter hospitalizations and lower charges, regardless of SOI. As care shifts towards specialized centers, this charge differential may have significant impact on future health care costs. LEVEL OF EVIDENCE: Level III Cost Effectiveness Study.

Defining the burden, scope, and future of vascular acute care surgery.

OBJECTIVE: The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. METHODS: A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death. RESULTS: Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0). CONCLUSIONS: The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and-similar to emergency general surgery-may benefit from dedicated training and practice models.

Acute Care Surgery: Defining the Economic Burden of Emergency General Surgery.

BACKGROUND: Trauma centers (TCs) have been shown to provide lifesaving, but more expensive, care when compared with non-TCs (NTC). Limited data exist about the economic impact of emergency general surgery (EGS) patients on health care systems. We hypothesized that the economic burden would be higher for EGS patients managed at TCs vs NTCs. METHODS: The Maryland Health Services Cost Review Commission database was queried from 2009 to 2013. The American Association for the Surgery of Trauma EGS ICD-9 codes were used to define the top 10 EGS diagnoses. Demographic characteristics, TC designation, severity of illness, and hospital charge data were collected. Differences in total charges between TCs and NTCs were analyzed by Wilcoxon test using SAS 9.3 software (SAS Institute). RESULTS: A total of 435,623 patients were included. Median age was 61 years (interquartile range 47 to 76 years) and 55.9% were female. Median length of stay was 4 days; 90.3% were admitted via emergency department; and overall mortality was 5.1%. Overall median charges were $11,081 for TC vs $8,264 for NTC (p < 0.0001). Minor, moderate, major, and extreme severities of illness all had higher charges at TC vs NTC with no ICU admissions, respectfully ($5,908 vs $5,243; $7,051 vs $6,003; $10,501 vs $8,777; and $23, 997 vs $18,381; p < 0.001). Care at TCs was nearly twice as expensive if patients were admitted to the ICU, even when stratifying by severity of illness. CONCLUSIONS: Emergency general surgery patients treated at TCs incurred increased costs compared with NTCs, independent of patient severity. These costs nearly doubled for those admitted to the ICU. As acute care surgery grows as a specialty, additional investigation is required to better understand the reasons for this cost differential.

Nontrauma open abdomens: A prospective observational study.

BACKGROUND: Damage-control surgery with open abdomen (OA) is described for trauma, but little exists regarding use in the emergency general surgery. This study aimed to better define the following: demographics, indications for surgery and OA, fascial and surgical site complications, and in-hospital/long-term mortality. We hypothesize that older patients will have increased mortality, patients will have protracted stays, they will require specialized postdischarge care, and the indications for OA will be varied. METHODS: A prospective observational study of emergency general surgery OA patients from June 2013 to June 2014 was performed. Demographics, clinical/operative variables, comorbidities, indications for procedure and OA, wound/fascial complications, and disposition were collected. Patients were stratified into age groups (≤ 60, 61-79, and ≥ 80 years). Six-month and 1-year mortality was determined by query of the Social Security Death Index. RESULTS: A total of 338 laparotomies were performed, of which 96 (28%) were managed with an OA. Median age was 61 years (interquartile range [IQR], 0-68 years), and 51% were male. The median Charlson Comorbidity Index was 2 (IQR, 1.5-5.1), and the median hospital stay was 25 days (IQR, 15-50 days). The most common indications for operation were perforated viscus/free air (20%), mesenteric ischemia (17%), peritonitis (16%), and gastrointestinal hemorrhage (12%). The most common indication for OA was damage control (37%). In the 63 patients with fascial closure, there were 9 (14%) wound infections and 6 (10%) fascial dehiscences. A total of 30% of the patients died in the hospital, and an additional six patients died 6 months after discharge. Patients in the oldest age stratum were more likely to die at 6 months than those in the lower strata. CONCLUSION: Older patients were more likely to die by 6 months, the median hospital stay was 3 weeks, and there were multiple indications for OA management. With a 6-month mortality of 36% and 70% of survivors requiring postdischarge care, this population represents a critically ill population meriting additional study. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Emergency General Surgery: Defining Burden of Disease in the State of Maryland.

Acute care surgery services continue expanding to provide emergency general surgery (EGS) care. The aim of this study is to define the characteristics of the EGS population in Maryland. Retrospective review of the Health Services Cost Review Commission database from 2009 to 2013 was performed. American Association for the Surgery of Trauma-defined EGS ICD-9 codes were used to define the EGS population. Data collected included patient demographics, admission origin [emergency department (ED) versus non-ED], length of stay (LOS), mortality, and disposition. There were 3,157,646 encounters. In all, 817,942 (26%) were EGS encounters, with 76 per cent admitted via an ED. The median age of ED patients that died was 74 years versus 61 years for those that lived (P < 0.001). Twenty one per cent of ED admitted patients had a LOS > 7 days. Of 78,065 non-ED admitted patients, the median age of those that died was 68 years versus 59 years for those that lived (P < 0.001). Twenty eight per cent of non-ED admits had LOS > 7 days. In both ED and non-ED patients, there was a bimodal distribution of death, with most patients dying at LOS ≤ 2 or LOS > 7 days. In this study, EGS diagnoses are present in 26 per cent of inpatient encounters in Maryland. The EGS population is elderly with prolonged LOS and a bimodal distribution of death.

Does regionalization of acute care surgery decrease mortality?

BACKGROUND: During the initial development of an Emergency General Surgery (EGS) service, severity of illness (SOI) can be expected to be high and should decrease as the service matures. We hypothesize that a matured regional EGS service would show decreasing mortality and length of stay (LOS) over time. METHODS: We performed a retrospective study of a prospectively collected EGS registry data from 2004 to 2009. Patients were included if they had been discharged from the EGS service and were stratified by year of discharge. Systemic inflammatory response syndrome, sepsis, shock, peritonitis, perforation, and acute renal failure were used as markers of SOI. Patients were defined as high acuity if they had one or more of these SOI markers. Differences in mortality, LOS, intensive care unit admissions, SOI, charges, and distance were compared across and between years using nonparametric statistical tests (Fisher's exact, Wilcoxon rank-sum, and Kruskal-Wallis tests). RESULTS: A total of 3,439 patients met study criteria. The mean age was 47 years ± 17.5 years. The majority of the patients were female (1,813, 47.3%). The overall LOS was 6.4 days ± 9.4 days (median, 4 days). In all, 2,331 (67.8%) of the patients underwent operation. Over the course of the study period, the SOI indicators stabilized at between 13% and 17% of the patient population with at least one indicator. During that time period, mortality steadily decreased from 4.9% to 1.3% (p < 0.5). CONCLUSION: Despite consistently high SOI, a dedicated and matured EGS service demonstrated a decrease in mortality and LOS.

Acute care surgery program: mentoring fellows and patient outcomes.

BACKGROUND: Acute care surgery programs have demonstrated that trauma patient outcomes have not changed with the addition of emergency general surgery (EGS) responsibilities. EGS patient outcomes and the mentoring of fellows on EGS service have not been previously studied. We hypothesize that EGS patient outcomes would not differ by provider on a service driven by evidence-based medicine (EBM) protocols. PATIENTS AND METHODS: Retrospective study of prospectively collected EGS repository. academic level I trauma center, and regional EGS referral center from 2003 to 2007. There were 14 faculty and seven fellows during the study period. EGS coverage is a full week, with weeknight coverage by the in-house trauma/EGS faculty. Fellows are mentored by designated faculty while on service, who discuss patients, assist in the OR, or assume care if necessary. Data collected included age, gender, LOS, ICU LOS, ventilator days, disposition (home/rehab), and infectious complications(IC) (VAP, BSI, UTI, SSI). Primary outcome was mortality. RESULTS: 1769 patients met study criteria. The mean age was 47.1 (+/-18), 47% were males. The average ICU LOS was 2.9 d (+/-7.9), ventilator d 2.6 (+/-7.6); 82.1% were discharged home and 13.7% were referred to rehab. There was no statistical difference in mortality, LOS, ICU LOS, disposition, ventilator d, and IC between faculty and fellow providers. CONCLUSIONS: An EGS service with EBM protocols assures consistency in patient outcomes independent of provider level: faculty or fellows. Our model for mentoring fellows did not decrease EGS patient outcomes.

The open abdomen in trauma: do infectious complications affect primary abdominal closure?

OBJECTIVE: One of the primary goals of damage control surgery in the trauma patient is primary closure of the abdomen. We hypothesized that extra-abdominal infections, such as those complicating injuries to the thorax, diaphragm, long bones, or musculoskeletal system, would decrease the likelihood of primary abdominal closure and increase hospital resource utilization in patients requiring open abdominal management. METHODS: The trauma registry of the American College of Surgeons (TRACS) was reviewed retrospectively from 1995-2002 for open abdomen technique and damage control surgery. The outcome was primary fascial closure or delayed closure. Patients who died prior to closure were excluded. We evaluated infectious complications, including ventilator-associated pneumonia (VAP), blood stream infection (BSI), and surgical site infection (SSI). Other parameters studied were multiple rib fractures, long bone fractures, chest injuries, diaphragm injuries, empyema, and transfusion requirements. Hospital charges were obtained from the hospital administrative database. Univariate, multivariate, and regression analyses were performed to identify the effects of infectious complications on primary abdominal closure, length of stay, total hospital charges, and disposition. RESULTS: Three hundred forty-four patients required the open abdomen technique: 67% received damage control laparotomy and 33% decompression of abdominal compartment syndrome. Two hundred seventy-six patients (80%) went on to abdominal closure of some form and constituted the primary study group. Primary abdominal closure was achieved in 180 (65%) with a mean time to closure of 3.5 days. Ventilator-associated pneumonia, BSI, and SSI were associated with lack of primary closure (p < 0.05). Increased blood transfusions also were associated with failure of primary closure (p < 0.05). Ventilator-associated pneumonia and BSI were associated with significantly greater lengths of stay in the intensive care unit (ICU) (24.2 days vs. 12.6 days and 30.5 days vs. 17.9 days; both p < 0.0001) and significantly greater total hospital charges (232,080 US dollar vs. 142,893 US dollar; 247,440 US dollar vs. 160,940 US dollar; and 264,778 US dollar vs. 170,447 US dollar; all p < 0.001). CONCLUSION: Inability to achieve primary abdominal closure was associated with infectious complications (VAP, BSI, and SSI) and large transfusion requirements. Infectious complications also significantly increased ICU utilization and hospital charges. Death was associated with BSI, femur fractures, and large transfusion requirements, whereas infectious complications did not have a significant impact on discharge disposition.

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan.

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.