Post-discharge Mental Healthcare and Emergency General Surgery Readmission for Patients with Serious Mental Illness.

OBJECTIVE: To determine the association between post-discharge mental healthcare and odds of readmission after emergency general surgery (EGS) hospitalization for patients with serious mental illness (SMI). BACKGROUND DATA: A mental health visit (MHV) after medical hospitalization is associated with decreased readmissions for patients with SMI. The impact of a MHV after surgical hospitalization is unknown. METHODS: Using Medicare claims, we performed a retrospective cohort study of hospitalized EGS patients with SMI aged >65.5 (2016-2018). EGS included colorectal, general abdominal, hepatopancreatobiliary, hernia, intestinal obstruction, resuscitation, and upper gastrointestinal conditions. SMI was defined as schizophrenia spectrum, mood, or anxiety disorders. The exposure was MHV within 30 days of discharge. The primary outcome was 30-day readmission. Secondary outcomes included emergency department presentation and psychiatric admission. Inverse probability weighting was used to evaluated outcomes. RESULTS: Of 88,092 analyzed patients, 11,755 (13.3%) had a MHV within 30 days of discharge. 23,696 (26.9%) of patients were managed operatively, 64,395 (73.1%) non-operatively. After adjustment for potential confounders, patients with a post-discharge MHV had lower odds of acute care readmission than patients without a MHV in both operative (OR 0.60; 95% CI: [0.40-0.90]) and non-operative (OR 0.67; 95% CI [0.53-0.84]) cohorts. There was no association between post-discharge MHV and ED presentation or psychiatric admission in the operative or non-operative groups. CONCLUSIONS: Post-discharge MHV after EGS hospitalization was associated with decreased odds of readmission for patients with SMI managed operatively and nonoperatively. In older EGS patients with SMI, coordination of MHVs may be a mechanism to reduce readmission disparities.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Belonging in Surgery: A validated instrument and single institutional pilot.

OBJECTIVE: The aim of this study was to develop and validate an instrument to measure Belonging in Surgery among surgical residents. SUMMARY BACKGROUND DATA: Belonging is the essential human need to maintain meaningful relationships and connections to one's community. Increased belongingness is associated with better well-being, job performance and motivation to learn. However, no tools exist to measure belonging among surgical trainees. METHODS: A panel of experts adapted a belonging instrument for use among United States surgery residents. After administration of the 28-item instrument to residents at a single institution, a Cronbach's alpha was calculated to measure internal consistency, and exploratory principal component analyses (PCA) were performed. Multiple iterations of analyses with successively smaller item samples suggested the instrument could be shortened. The expert panel was reconvened to shorten the instrument. Descriptive statistics measured demographic factors associated with Belonging in Surgery. RESULTS: The overall response rate was 52% (114 responses). The Cronbach's alpha among the 28 items was 0.94 (95% CI: 0.93-0.96). The exploratory PCA and subsequent Promax rotation yielded one dominant component with an eigenvalue of 12.84 (70% of the variance). The expert panel narrowed the final instrument to 11 items with an overall Cronbach's alpha of 0.90 (95% CI: 0.86, 0.92). Belonging in Surgery was significantly associated with race (Black and Asian residents scoring lower than White residents), graduating with one's original intern cohort (residents who graduated with their original class scoring higher than those that did not), and inversely correlated with resident stress level. CONCLUSIONS: An instrument to measure Belonging in Surgery was validated among surgical residents. With this instrument, Belonging in Surgery becomes a construct that may be used to investigate surgeon performance and well-being.

Variation in Hospital Performance for General Surgery in Younger and Older Adults: A Retrospective Cohort Study.

OBJECTIVE: To compare hospital surgical performance in older and younger patients. SUMMARY BACKGROUND DATA: In-hospital mortality after surgical procedures varies widely between hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown. METHODS: We performed a retrospective cohort study of patients ≥18 years undergoing one of ten common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into two populations: Medicare ≥65 (older adult) and non-Medicare <65 (younger adult) patients. Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population. RESULTS: We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs. 29.8%; P=0.059) and significantly higher failure-to-rescue rates (16.0% vs. 4.0%; P<0.001). Among younger adults, high- relative to low-mortality hospitals had higher complication (15.4% vs. 12.1%; P<0.001) and failure-to-rescue rates (8.3% vs. 0.7%; P<0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 (P<0.001). CONCLUSIONS: High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes.

Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable.

OBJECTIVE: To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND: Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS: We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS: For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS: The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis.

OBJECTIVE: To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions. BACKGROUND: EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity. METHODS: Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions. RESULTS: Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients. CONCLUSIONS: The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions.

INTRODUCTION: Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS: We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS: A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS: The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study.

INTRODUCTION: Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively. METHODS: EGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal-Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models. RESULTS: Among 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001). CONCLUSIONS: HFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.

A study analyzing outcomes after bariatric surgery by primary language.

BACKGROUND: Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language. METHODS: This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race. RESULTS: Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes. CONCLUSIONS: Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities: A Retrospective Observational Study.

BACKGROUND: Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients. OBJECTIVE: The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery. RESEARCH DESIGN: Retrospective observational study using state discharge data. SUBJECTS: Medicare beneficiaries who underwent an operation for an emergency general surgery condition in New York, Florida, or Pennsylvania (2012-2013). MEASURES: Patients were classified as multimorbid using Qualifying Comorbidity Sets (QCSs). Outcomes included in-hospital mortality, hospital length of stay and discharge status. RESULTS: Of 312,160 patients, a large minority (37.4%) were multimorbid. Non-QCS patients did not have a specific combination of comorbidities to satisfy a QCS, but 64.1% of these patients had 3+ comorbid conditions. Multimorbidity was associated with increased in-hospital mortality (10.5% vs. 3.9%, P <0.001), decreased rates of discharge to home (16.2% vs. 37.1%, P <0.001), and longer length of stay (10.4 d±13.5 vs. 6.7 d±9.3, P <0.001) when compared with non-QCS patients. Risks varied between individual QCSs. CONCLUSIONS: Multimorbidity, defined by satisfying a specific QCS, is strongly associated with poor outcomes for older patients requiring emergency general surgery in the United States. Variation in risk of in-hospital mortality, discharge status, and length of stay between individual QCSs suggests that multimorbidity does not carry the same prognostic weight as having multiple comorbidities-the specifics of which are important in setting expectations for individual, complex patients.

Is There Color or Sex Behind the Mask and Sterile Blue? Examining Sex and Racial Demographics Within Academic Surgery.

BACKGROUND: The lack of underrepresented minorities has been a persistent issue within the surgical workforce. Equal sex representation has also been a problem in surgery. Underrepresented minorities females face the unique challenge of being a minority in both race and sex. OBJECTIVE: The objective of this retrospective cross-sectional study is to determine the racial and sex demographics of medical trainees and faculty and determine the degree to which minority women are underrepresented at higher ranks and leadership. METHODS: Race and sex demographic data for all medical students, surgical residents and faculty was extracted from the AAMC data files. This data was compared to the US population using chi squared tests. Race and sex breakdowns of the different surgical subspecialties was also analyzed using chi squared tests. Demographics of surgical faculty at various ranks are also reported. RESULTS: White men made up 37% of all surgical residents. Black men made up only 1.9% of all surgical residents whereas Black women made up 2.6%. The subspecialty with the smallest percentage of Black women was Orthopedic Surgery with 0.6%. The specialty with the highest representation of Black women was Ob/Gyn with 6.2%. There was a decrease in representation of Black women with each increase in professional rank, with 2.8%, 1.6%, and 0.7% for assistant, associate, and full professor, respectively, as compared to Black men, who as a percentage, remained stable at the various ranks with 2.1%, 2.4%, and 2.1% for assistant, associate, and full professor, respectively. CONCLUSIONS: There is a striking lack of minority women in surgery. This trend is amplified as surgeons progress from student, to resident, to attending, and then to leadership positions.

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.

Effect of Serious Mental Illness on Surgical Consultation and Operative Management of Older Adults with Acute Biliary Disease: A Nationwide Study.

BACKGROUND: Mental illness is associated with worse outcomes after emergency general surgery. To understand how preoperative processes of care may influence disparate outcomes, we examined rates of surgical consultation, treatment, and operative approach between older adults with and without serious mental illness (SMI). STUDY DESIGN: We performed a nationwide, retrospective cohort study of Medicare beneficiaries aged 65.5 years or more hospitalized via the emergency department for acute cholecystitis or biliary colic. SMI was defined as schizophrenia spectrum, mood, and/or anxiety disorders. The primary outcome was surgical consultation. Secondary outcomes included operative treatment and surgical approach (laparoscopic vs open). Multivariable logistic regression was used to examine outcomes with adjustment for potential confounders related to patient demographics, comorbidities, and rates of imaging. RESULTS: Of 85,943 included older adults, 19,549 (22.7%) had SMI. Before adjustment, patients with SMI had lower rates of surgical consultation (78.6% vs 80.2%, p < 0.001) and operative treatment (68.2% vs 71.7%, p < 0.001), but no significant difference regarding laparoscopic approach (92.0% vs 92.1%, p = 0.805). In multivariable regression models with adjustment for confounders, there was no difference in odds of receiving a surgical consultation (odds ratio 0.98 [95% CI 0.93 to 1.03]) or undergoing operative treatment (odds ratio 0.98 [95% CI 0.93 to 1.03]) for patients with SMI compared with those without SMI. CONCLUSIONS: Older adults with SMI had similar odds of receiving surgical consultation and operative treatment as those without SMI. As such, differences in processes of care that result in SMI-related disparities likely occur before or after the point of surgical consultation in this universally insured patient population.

Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures.

Importance: Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown. Objective: To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults. Design, Setting, and Participants: This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race. Exposure: Primary care utilization in the year prior to presentation for an EGS operation. Main Outcome and Measures: In-hospital, 30-day, 60-day, 90-day, and 180-day mortality. Results: A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different. Conclusions and Relevance: In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.

Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries.

BACKGROUND: Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. METHODS: This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. RESULTS: In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. CONCLUSIONS: Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.

Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial.

Objective: To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial. Summary background data: Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined. Methods: A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage. Results: A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001). Conclusion: This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted. Level of evidence: NA.

Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study.

BACKGROUND: Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN: Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS: Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS: Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.

Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients.

Importance: A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department. Objective: To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition. Design, Setting, and Participants: This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal. Exposures: Black vs White race. Main Outcomes and Measures: Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition. Results: A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46). Conclusions and Relevance: In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.

Processes to Create a Culture of Surgical Patient Safety.

This article discusses the processes, interventions, and methods by which health care systems can change the culture of their workplace to promote safety. The importance of this culture shift is discussed, as well as an organizational approach, highlighting the importance of investment of time and resources to the cause. Efforts must include an educational focus on patient safety where a culture of patient safety is emphasized. This attitude along with several specific key interventions, including, measurement, teamwork, briefings, checklists, and developmental infrastructure, are discussed.