University of Massachusetts Medical School, Worcester.
University of Wisconsin, Department of Surgery, Madison.
JAMA Surg. 2018 Feb 1;153(2):150-159. doi: 10.1001/jamasurg.2017.3799.
Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood.
To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging.
DESIGN, SETTING, AND PARTICIPANTS: A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached.
Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS.
We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access).
Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities.
Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.
由于缺乏足够的紧急护理基础设施和普通外科劳动力的减少，美国在获得紧急普通外科 (EGS) 护理方面面临危机。急性护理外科学 (ACS)，一种组织化的创伤、普通外科和重症监护系统，是一种被提议的解决方案;然而，ACS 的传播仍知之甚少。
调查 ACS 护理模式的地理扩散情况，并描述 ACS 实施滞后的社区特征。
设计、地点和参与者：开发了一项关于 EGS 实践的全国性调查，该调查于 2015 年 8 月至 10 月间在为成人提供 EGS 的美国所有 2811 家急症医院进行了测试和实施。邀请了负责这些医院 EGS 覆盖的外科医生。如果这些外科医生没有对初始调查实施做出回应，那么只有 1 名普通外科医生的医院将联系第二外科医生或首席医疗官。
将 ACS 实施的调查回复与地理编码的医院数据和全国人口普查数据相关联，以确定 ACS 的地理扩散和可及性。
我们衡量了具有 ACS 护理模式的医院的分布情况，以及随着时间的推移（扩散）和按美国以居民的社会人口特征为特征的县（获取）的分布情况。
调查回应率为 60%（n=1690）；2015 年有 272 家医院实施了 ACS，从 2001 年的 34 家稳步增加到 2010 年的 125 家。急性护理外科学的实施并不统一。农村地区的 ACS 服务有限，人口超过 75 百分位的县的医院实施 ACS 的可能性是人口少于 25 百分位的县的医院的 5.4 倍（95%CI，1.66-7.35）。成人中没有大学学历的比例较高的社区，ACS 服务也有限（OR，3.43；95%CI，1.81-6.48）。然而，将 EGS 纳入 ACS 模式可能是解决贫困、黑人和西班牙裔社区不平等问题的潜在手段。
了解和解决社区间 ACS 实施方面的差距对于确保美国普通外科急症患者的健康公平至关重要。
