From the School of Medicine (A.M., S.V., N.L.), Johns Hopkins University, Baltimore, Maryland; Department of Surgery (A.M.), NewYork-Presbyterian, Columbia University Medical Center, New York, New York; Department of Surgery (D.E., E.R.H., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (B.J.), University of Arizona College of Medicine, Tucson, Arizona; and Department of Surgery (Z.C.), Brigham and Women's Hospital, Boston, Massachusetts.
J Trauma Acute Care Surg. 2019 Feb;86(2):189-195. doi: 10.1097/TA.0000000000002142.
As the aging American population poses unique challenges to acute care services, we determined if either hospital proportion or annual volume of geriatric patients undergoing emergency general surgery (EGS) procedures is associated with outcomes.
Using criteria from the American Association of the Surgery of Trauma, we identified five EGS procedures in the 2012-2015 Nationwide Inpatient Sample common in geriatric patients (65+ years). We defined hospital proportion as the fraction of geriatric EGS patients divided by all EGS patients, where volume was the raw number of geriatric EGS patients. We then divided hospitals into quartiles both by proportion and then by volume of geriatric patients. Multivariable logistic regressions compared four outcomes between these quartiles: mortality, complications, failure to rescue (FTR; death after a complication), and extended length of stay (LOS; procedure-specific top decile of patients).
We identified 25,084 complex EGS procedures in geriatric patients at 3,528 hospitals (mortality, 10.6%; complications, 30.5%; FTR, 27.7%; extended LOS, 9.1%). The median hospital proportion of geriatric patients among EGS procedures was 42.8% (interquartile range, 33.3-52.2%), whereas the median hospital geriatric EGS volume after nationwide weighting was 40 per year (interquartile range, 20-70/year). After adjustment, the lowest hospital proportion quartile relative to the highest was associated with adverse outcomes: mortality (odds ratio, 1.21 [95% confidence interval, 1.03-1.44]), complications (1.16 [1.05-1.29]), FTR (1.32 [1.08-1.63]), and extended LOS (1.30 [1.12-1.50]). The lowest volume quartile relative to the highest was not associated with adverse outcomes. As the hospital proportion of geriatric patients increased by 10%, the odds of all adverse outcomes decreased: mortality by 7%, complications by 4%, FTR by 9%, and extended LOS by 8%.
When accounting for both, hospital proportion of geriatric EGS patients but not hospital volume is associated with postoperative outcomes, having important implications for quality improvement initiatives, benchmarking endeavors, and health services research.
Care management, level IV; prognostic, level III.
随着美国老年人口给急症护理服务带来独特挑战，我们确定接受急症普通外科（EGS）治疗的老年患者的医院比例或每年的患者数量是否与结果相关。
我们使用美国外科创伤协会的标准，确定了 2012-2015 年全国住院患者样本中五种常见于老年患者（65 岁以上）的 EGS 手术。我们将医院比例定义为接受 EGS 治疗的老年患者数量与所有 EGS 患者数量之比，而数量则是接受 EGS 治疗的老年患者数量。然后，我们根据老年患者的比例和数量将医院分为四组。多变量逻辑回归比较了这四组之间的四个结果：死亡率、并发症、救援失败（FTR；并发症后死亡）和延长住院时间（特定手术中患者的前十分位数）。
我们在 3528 家医院中识别出 25084 例老年患者的复杂 EGS 手术（死亡率为 10.6%；并发症为 30.5%；FTR 为 27.7%；延长的 LOS 为 9.1%）。EGS 手术中老年患者的中位数医院比例为 42.8%（四分位距，33.3-52.2%），而全国加权后的中位数医院老年 EGS 数量为每年 40 例（四分位距，20-70/年）。经过调整，与最高比例组相比，医院比例最低的四分之一组与不良结果相关：死亡率（比值比，1.21 [95%置信区间，1.03-1.44]）、并发症（1.16 [1.05-1.29]）、FTR（1.32 [1.08-1.63]）和延长 LOS（1.30 [1.12-1.50]）。与最高比例组相比，医院比例最低的四分之一组与不良结果无关。当老年患者在 EGS 患者中的比例增加 10%时，所有不良结果的几率都会降低：死亡率降低 7%，并发症降低 4%，FTR 降低 9%，延长 LOS 降低 8%。
在考虑到老年 EGS 患者的医院比例和数量这两个因素时，医院比例与术后结果相关，这对质量改进计划、基准测试工作和卫生服务研究具有重要意义。
护理管理，IV 级；预后，III 级。
