Department of Surgery, University of Cincinnati College of Medicine, OH 45267-0558, USA.
J Am Coll Surg. 2011 Jan;212(1):20-28.e1. doi: 10.1016/j.jamcollsurg.2010.09.026.
Surgical quality improvement has focused on elective general surgery (ELGS) outcomes despite the substantial risk associated with emergency general surgery (EMGS) procedures. Furthermore, any differences in the quality of care provided to EMGS versus ELGS patients are not well described. We compared risk factors and risk-adjusted outcomes associated with EMGS and ELGS procedures to assess whether hospitals have comparable outcomes across these procedures.
Using American College of Surgeons National Surgical Quality Improvement Program data (2005 to 2008), regression models were constructed for 30-day overall morbidity, serious morbidity, and mortality among all patients, EMGS patients, and ELGS patients. Observed-to-expected (O/E) ratios were calculated from models based on EMGS or ELGS patients. Association of hospital performance after EMGS versus ELGS procedures was assessed by evaluating correlations of O/E ratios; agreement in outlier status (hospitals where O/E confidence intervals [CI] do not overlap 1.0) was evaluated with weighted kappa.
Of 473,619 procedures, 67,445 (14.2%) patients underwent an EMGS procedure. EMGS patients were more likely to experience any morbidity (odds ratio [OR] 1.20; 95% CI 1.16 to 1.23), serious morbidity (OR 1.26; 95% CI 1.21 to 1.30), and mortality (OR 1.39; 95% CI 1.30 to 1.48). Correlation between O/E ratios for EMGS and ELGS were moderate to low (overall morbidity = 0.48, p < 0.0001; serious morbidity = 0.41, p < 0.0001, mortality = 0.18, p = 0.01). Outlier status was not consistent across EMGS and ELGS, with only slight agreement (overall morbidity = 0.18, p < 0.0001; serious morbidity = 0.16, p = 0.001, mortality = 0.19, p = 0.01).
EMGS patients are at substantially greater risk than ELGS patients for adverse events. Hospitals do not appear to have highly consistent performance across EMGS and ELGS outcomes. Processes of care that afford improved outcomes to EMGS patients need to be identified and disseminated.
尽管急诊普通外科（EMGS）手术存在较大风险，但外科质量改进一直集中在择期普通外科（ELGS）的结果上。此外，EMGS 患者与 ELGS 患者之间提供的护理质量差异尚未得到很好的描述。我们比较了 EMGS 和 ELGS 手术相关的风险因素和风险调整结果，以评估医院在这些手术中的结果是否具有可比性。
利用美国外科医师学院国家外科质量改进计划数据（2005 年至 2008 年），为所有患者、EMGS 患者和 ELGS 患者构建了 30 天整体发病率、严重发病率和死亡率的回归模型。基于 EMGS 或 ELGS 患者的模型计算观察到的与预期的（O/E）比值。通过评估 EMGS 后与 ELGS 后手术的医院绩效相关性来评估医院绩效的相关性；通过评估加权 kappa，评估离群状态（O/E 置信区间 [CI] 不重叠 1.0 的医院）的一致性。
在 473619 例手术中，有 67445（14.2%）例患者接受了 EMGS 手术。EMGS 患者更有可能经历任何发病率（优势比 [OR] 1.20；95%CI 1.16 至 1.23）、严重发病率（OR 1.26；95%CI 1.21 至 1.30）和死亡率（OR 1.39；95%CI 1.30 至 1.48）。EMGS 和 ELGS 的 O/E 比值之间的相关性为中等至低度（整体发病率=0.48，p<0.0001；严重发病率=0.41，p<0.0001，死亡率=0.18，p=0.01）。EMGS 和 ELGS 的离群状态不一致，仅略有一致性（整体发病率=0.18，p<0.0001；严重发病率=0.16，p=0.001，死亡率=0.19，p=0.01）。
EMGS 患者发生不良事件的风险明显高于 ELGS 患者。医院在 EMGS 和 ELGS 结果方面的表现似乎没有高度一致。需要确定并传播改善 EMGS 患者结果的护理流程。
