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Article 1
Cost of specific emergency general surgery diseases and factors associated with high-cost patients. Ogola GO and Shafi S. J Trauma and Acute Care Surg. 2016 Feb;80(2):265-71.
The authors of this manuscript conducted a retrospective analysis of costs for patients hospitalized with an emergency general surgery (EGS) condition using the National Inpatient Sample (NIS) 2010 data. This was chosen to estimate nationwide incidence of disease for inpatients. Diagnoses were grouped into 31 EGS diseases. Cost-to-charge ratios (CCRs) were extracted from the NIS. These are used by hospitals to convert charges into costs. The data was adjusted for patient and hospital mix. The purpose of this analysis was to estimate the cost of hospitalization for specific EGS diseases and to identify factors associated with high-cost hospitalization.
Three main findings of the study were: 1) only 9 EGS diseases account for 80% of EGS hospitalizations and 74% of the cost; 2) procedures, especially major operative procedures, are the most important predictor of high-cost hospitalizations; 3) there are significant regional variations in the cost of EGS care. The nine EGS diseases in descending order were: soft tissue infection, gallbladder, intestinal obstruction, pancreatitis, diverticular disease, appendix, gastrointestinal bleed, peptic ulcer disease, Clostridium dificile. Multiple predictors were found to be independently associated with high-cost hospitalization and were grouped into five categories: 1) increasing number of procedures and the use of a major operative procedure were most important predictors of high cost and accounted for more than 76.2% of the variability in costs; 2) regional variations exist – the West is the most expensive; 3) hospital characteristics explained 6.0% variability – public not-for-profit, teaching and small bed size were associated with high cost; 4) payor type – Medicare and Medicaid was associated with high cost; 5) patient characteristics – older age, male, white, transfers, comorbidities were associated with high costs.
This manuscript is the first to estimate the cost of hospitalization for specific EGS disease. Emergency surgery is garnering more interest within acute care surgery. Mergers and acquisitions have occurred and hospitals have become components of health systems. Some of these systems have become regional gorillas and marginalized the important county facility. County safety-net teaching hospitals play a critical role in regional healthcare and education. Although further study is warranted, these results should be considered in the regional evolution of emergency general surgery.
Article 2
Outcomes after emergency abdominal surgery in patients with advanced cancer: opportunities to reduce complications and improve palliative care. Cauley CE, Panizales, Reznor G, et al. J Trauma Acute Care Surg. 2015 Sep;79(3):399-406.
The authors conducted a multi-institutional cohort study of patients with a preoperative diagnosis of disseminated cancer that underwent emergent major abdominal operations for either intestinal obstruction or perforation. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was mined. It included patients from hospitals that were enrolled from 2005 to 2012. The goals of the study were: 1) to improve surgeon’s ability to prognosticate patient outcomes and inform perioperative conversations about treatment preferences and decision for intervention among patients with advanced cancer who undergo emergency surgery for perforation or obstruction, and 2) describe a cohort that could benefit from perioperative palliative care.
The study showed that 1 in 3 patients with disseminated cancer whom underwent surgery for perforation and 1 in 6 who undergo surgery for obstruction died within 30 days of their operation. Most who had surgery for perforation (69%) and almost half (47%) of patients for obstruction developed a postoperative complication. Few patients survived. For those with perforation 26% died in the hospital and 34% died within 30-days. 12% were discharged home. For those with obstruction, 11% died in the hospital and 18% died within 30-days. 60% were discharged to a nursing facility. Preoperative factors that were found to be predictors of 30-day mortality included: renal failure, septic shock, dyspnea at rest, ascites, and dependent functional status.
Surgeons are often consulted to evaluate patients with intestinal perforation or obstruction. The information in this study should be helpful to the patient, patient’s family, and healthcare team in setting expectations – post op complications, discharge location, and overall survival. It also provides a stimulus to involve palliative care early.
Article 3
Surgeons’ Perspective on Avoiding Nonbeneficial Treatments in Seriously Ill Older Patients with Surgical Emergences: A Qualitative Study. Cauley CE, Block SD, Koritsanszky LA, et al. Journal of Palliative Medicine. 2016 May;19(5):529-37.
The population of older patients is rising and there are increasing numbers of older patients presenting to the hospital with emergent surgical conditions. National data show patients ≥ 65 years old who have an emergent laparotomy 16% die in the hospital and 30% die within 6-months. Most suffer post op complications (up to 80%). Previous studies demonstrated that patients value function, cognition, and time at home above longevity. Based on these premises, the authors conducted semi-structured interviews of emergency general surgeons (24) to identify factors important to surgical decision-making and end of life (EOL) communication.
Six domains describing factors that affect communication during surgical emergencies were identified: 1) surgeon responsibility, 2) assessing risk, 3) appropriateness, 4) patient and family, 5) palliative care, 6) system factors.
Surgeons felt that “discussing EOL decisions is our/surgeon’s responsibility”; agreed that it is best if EOL issues are discussed before surgical consultation:
- Surgeons had a difficult time assessing risk – difficulty formulating prognosis due to lack of clear data; and for patients with a poor prognosis some surgeons felt surgery was worthwhile even for a small chance at survival.
- Discussions on whether an operation could or should be done, and how such procedure(s) is in line with patient’s goals and how those goals fit into the burdens and benefits of an intervention can be difficult. Participants in the study felt that patients’ poor understanding about their underlying condition’s prognosis hinders their ability to appreciate how an acute event will change there quality of life (QOL), impacting their ability to make goal-concordant decisions.
- Patient’s emotions and religious beliefs about illness and death were described as factors that influence a patient’s or family’s ability to absorb information, as well as surgeon’s decision-making. In these situations, surgeons felt meeting the patient for the first time provided a “benefit of being a fairly objective, second eye”.
- Requesting palliative care consultation was limited by a myriad of concerns, it was not their place, lack of access to palliative care in the emergency department, or beliefs that palliative care would not solve the patient’s problem.
- Time to discuss thoroughly all of the options with a family when the patient’s condition was serious or death was imminent was cited as a factor. Other system factors included: rotating staff, incomplete records, inability to reach other providers in a timely fashion.
This study shed some light on the surgeon’s perspective and decision-making with seriously ill older patients who have acute surgical conditions. Bridging the communication gap is still a challenge. Early involvement of palliative care may help bridge this gap. More outcome data would help with decision-making. End of life discussions should happen prior to the development of emergent conditions to prepare seriously ill patients for decision-making.
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