From the Comparative Effectiveness and Clinical Outcomes Research Center (R.C., R.B., T.A.-A., B.Z., M.F.), Riverside University Health System Medical Center, Moreno Valley, California; Department of Surgery (R.C., T.A.-A.), Loma Linda University School of Medicine, Loma Linda, California; University of California Riverside School of Medicine (R.B.), Riverside, California.
J Trauma Acute Care Surg. 2022 Feb 1;92(2):296-304. doi: 10.1097/TA.0000000000003463.
The impact of interhospital transfer on outcomes of patients undergoing emergency general surgery (EGS) procedures is incompletely studied. We set out to determine if transfer before definitive surgical care leads to worse outcomes in EGS patients.
Using the National Surgical Quality Improvement Project database (2013-2019), a retrospective cohort study was conducted including nine surgical procedures encompassing 80% of the burden of EGS diseases, performed on an urgent/emergent basis. The procedures were classified as low risk (open and laparoscopic appendectomy and laparoscopic cholecystectomy) and high risk (open cholecystectomy, laparoscopic and open colectomy, lysis of adhesions, perforated ulcer repair, small bowel resection, and exploratory laparotomy). Time to surgery was recorded in days. The impact of interhospital transfer on outcomes (mortality, major complications, 30-day reoperations, and 30-day readmissions) and length of stay, according to procedure risk and time to surgery, were analyzed by multivariate logistic regression and inverse probability treatment of the weighting with treatment effect in the treated.
A total of 329,613 patients were included in the study (284,783 direct admission and 44,830 transfers). Adjusted mortality (3.1% vs. 10.4%; adjusted odds ratio [AOR], 1.28; p < 0.001), major complications (6.7% vs. 18.9%; AOR, 1.39; p < 0.001), 30-day reoperations (3.1% vs. 6.4%; AOR, 1.22; p < 0.001), and length of stay (2 vs. 5) were higher in transferred patients. Transfer had no effect on 30-day readmissions (6% vs. 8.5%; AOR, 1.04; p = 0.063). These results were also observed in high-risk surgery patients and in the late surgery group. The results were further confirmed after robust propensity score weighting was performed.
We have demonstrated that delays to surgical intervention affect outcomes and that interhospital transfer of EGS patients for definitive surgical care has a negative impact on mortality, development of postoperative complications, and reoperations in patients undergoing high-risk EGS procedures. These findings may have important implications for regionalization of EGS care.
Prognostic/epidemiological, level III.
目前对于接受急诊普通外科（EGS）手术的患者，院内转院对其预后的影响尚未完全阐明。本研究旨在明确在确定性外科治疗前进行转院是否会导致 EGS 患者的预后更差。
利用国家外科质量改进计划数据库（2013-2019 年），进行了一项回顾性队列研究，共纳入 9 项外科手术，涵盖 80%的 EGS 疾病负担，均为紧急/急诊手术。这些手术分为低危（开放性和腹腔镜阑尾切除术及腹腔镜胆囊切除术）和高危（开放性胆囊切除术、腹腔镜和开放性结肠切除术、粘连松解术、穿孔性溃疡修补术、小肠切除术和剖腹探查术）。记录手术时间（以天为单位）。根据手术风险和手术时间，采用多变量逻辑回归和倾向评分加权的逆概率处理方法，分析院内转院对预后（死亡率、主要并发症、30 天再手术和 30 天再入院）和住院时间的影响。
共纳入 329613 例患者（直接入院 284783 例，转院 44830 例）。校正后，转院患者的死亡率（3.1%比 10.4%；校正比值比[OR]，1.28；p < 0.001）、主要并发症发生率（6.7%比 18.9%；OR，1.39；p < 0.001）、30 天再手术率（3.1%比 6.4%；OR，1.22；p < 0.001）和住院时间（2 天比 5 天）更高。但转院对 30 天再入院率（6%比 8.5%；OR，1.04；p = 0.063）没有影响。高危手术患者和手术时间较晚的患者也观察到了类似的结果。进行稳健的倾向评分加权后，结果仍然成立。
本研究表明，外科干预的延迟会影响预后，EGS 患者进行确定性外科治疗的院内转院会对高危 EGS 手术患者的死亡率、术后并发症的发生和再手术产生负面影响。这些发现可能对外科治疗的区域化具有重要意义。
预后/流行病学，III 级。
