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Background About 19% of the United States population lives in rural areas and is served by only 10% of the physician workforce. If this misdistribution represents a shortage of available surgeons, it is possible that outcomes for rural patients may suffer. The objective of this study was to explore differences in outcomes for emergency general surgery (EGS) conditions between rural and urban hospitals using a nationally representative sample. Methods Data from the 2007-2011 National Inpatient Sample were queried for adult patients (≥18 years) with a primary diagnosis consistent with an EGS condition, as defined by the American Association for the Surgery of Trauma. Urban and rural patients were matched on patient-level factors using coarsened exact matching. Differences in outcomes including mortality, morbidity, length of stay (LOS), and total cost of hospital care were assessed using multivariable regression models. Analogous counterfactual models were used to further examine hypothetical outcomes, assuming that all patients had been treated at urban centers. Results A total of 3,749,265 patients were admitted with an EGS condition during the study period. Of 3259 hospitals analyzed, 40.2% ( n = 1310) were rural; they treated 14.6% of patients. Relative to urban centers, EGS patients treated at rural centers had higher odds of in-hospital mortality (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.21-1.28) and lower odds of major complications (OR: 0.98; 95% CI: 0.96-0.99). Rural patients had 0.51 d (95% CI: 0.50-0.53) shorter LOS and $744 (95% CI: 712-774) higher cost of hospitalization compared to urban patients. In counterfactual models overall odds of death decreased by 0.05%, whereas the overall odds of complications increased by 0.02%. Overall difference in LOS and total costs were comparable with absolute differences of 0.08 d and $98, respectively. Conclusions Despite the statistically significant difference in mortality and cost of care at rural versus urban hospitals, the magnitude of absolute differences is sufficiently small to indicate limited clinical importance. Large urban centers are designed to manage complex cases, but our results suggest that for cases appropriate to treat in rural hospitals, equivalent outcomes are found. These findings will inform future work on rural outcomes and provide impetus for regionalization of care for complex EGS presentations. [ABSTRACT FROM AUTHOR]

Introduction Burn center verification was implemented to ensure burn patients receive the best quality of care. As part of the of the organized burn care system, trauma centers that do not have a burn center within the hospital should refer burn patients to a designated burn center. However, more than 30% of burn patients are still being taken care of in non-verified burn centers. Our aim was to determine if trauma center status conferred a benefit in outcomes in a national sample of burn patients. Methods This is a retrospective study using State Inpatient Databases of 22 states in 2014. The inclusion criteria were all patients admitted for burn injury (ICD-9 codes 940–949). Hospitals were categorized as ABA verified centers (VBC) and non-verified burn centers (NVBC), as well as trauma centers (TC) and non-trauma centers (NTC) based on verification status at the time of admission. Main Outcomes were in-hospital mortality and length of hospitalization (LOS). Stratifying by burn center verification status, multivariable regression was used to identify the association between trauma center status and the outcomes. Results A total of 15,982 burn patients were identified. The overall in-hospital mortality rate was 2.45%. In our sample, we only had 26 hospitals that were both a TC and VBC (Table 1). The majority of patients (54%) were treated at a NVBC/TC. In unadjusted analysis, amongst verified centers, there was no difference in mortality between TC and NTCs (3.2% vs. 3.0%, p=0.877), but NTCs had longer LOS (14.7 vs. 10 d, p< 0.001). Amongst non-verified centers, TCs had higher mortality when compared with NTCs (2.4% vs. 1.1%, p< 0.001), but TCs had longer LOS (8.3 vs. 7.2 d, p=0.007). After adjusted analysis, within VBC, TC status was associated with shorter LOS (Coef -3.28, 95% CI -5.37 – -1.19, p=0.002), but not associated with mortality (OR 1.21, 95% CI 0.50 – 2.89, p=0.667). After adjusted analysis, within NVBC, TC status was associated with longer LOS (Coef 2.37, 95% CI 1.70 – 3.04, p< 0.001) and with mortality (OR 3.70, 95% CI 2.10 – 6.51). Conclusions Trauma center status does not confer any benefit for burn patient outcomes within the burn care verification system. Despite the regionalization of burn care through the development of verified burn centers, the majority of burn patients are receiving care at trauma centers with a non-verified burn center within the hospital. [ABSTRACT FROM AUTHOR]

Gender disparities in resident operative experience have been described; however, their etiology is poorly understood, and racial/ethnic disparities have not been explored. This study investigated the relationship between gender, race/ethnicity, and surgery resident case volumes. A retrospective analysis of graduating general surgery resident case logs (2010-2020) at an academic medical center was performed. Self-reported gender and race/ethnicity data were collected from program records. Residents were categorized as underrepresented in medicine (URM) (Black, Hispanic, Native American) or non-URM (White, Asian). Associations between gender and URM status and major, chief, and teaching assistant (TA) mean case volumes were analyzed using t -tests. The cohort included 80 residents: 39 female (48.8%) and 17 URM (21.3%). Compared to male residents, female residents performed fewer TA cases (33 versus 47, P < 0.001). Compared to non-URM residents, URM residents graduated with fewer major (948 versus 1043, P = 0.008) and TA cases (32 versus 42, P = 0.038). Male URM residents performed fewer TA cases than male non-URM residents (32 versus 50, P = 0.031). Subanalysis stratified by graduation year demonstrated that from 2010 to 2015, female residents performed fewer chief (218 versus 248, P = 0.039) and TA cases (29 versus 50, P = 0.001) than male residents. However, from 2016 to 2020, when gender parity was achieved, no significant associations were observed between gender and case volumes. Female and URM residents perform fewer TA and major cases than male non-URM residents, which may contribute to reduced operative autonomy, confidence, and entrustment. Prioritizing gender and URM parity may help decrease case volume gaps among underrepresented residents. [ABSTRACT FROM AUTHOR]

Introduction: The first states began implementing the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (ACA) in 2014. Studies have yet to address its impact on burn patients.Methods: Burn patients in geographic regions that expanded Medicaid coverage were compared to patients in regions that did not expand Medicaid before and after implementation of the ACA using bivariate statistics and a difference-in-differences model. A multivariable logistic regression was used to identify factors associated with having Medicaid insurance. The primary outcome of this study was the rate of Medicaid insurance.Results: Of 25,331 discharges, we found greater increases in Medicaid coverage after the ACA in the Medicaid expander regions (23.4-40.2%) compared to the non-expander regions (18.5-20.1%). The difference-in-differences estimate between the expander and non-expander regions was 0.15 (95% CI: 0.11-0.18, p < 0.001). Patients admitted in expander regions were more likely to be insured by Medicaid (OR 1.57 [95%CI 1.21-2.05]), as were patients of Black race (OR 1.25 [95%CI 1.19-1.32), Hispanic ethnicity (OR 1.29 [95%CI 1.14-1.46]), and female sex (OR 1.59 [95%CI 1.11-2.27]). We also found a significant interaction between time period (pre-ACA/post-ACA) and expander region location (OR 2.10 [95%CI 1.67-2.62]).Conclusions: The Medicaid expansion provision of the ACA led to increased Medicaid coverage among burn patients which was significantly higher in areas with widespread implementation of the expansion. [ABSTRACT FROM AUTHOR]

Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI. This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality. There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8). Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families. [ABSTRACT FROM AUTHOR]

Background Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy. Methods An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007–2011). All patients with an ICD-90-CM diagnosis of “acute appendicitis” (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors. Results There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14–0.36]), stayed in hospital longer (0.83 d [0.36–1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13–2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes. Conclusions Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings. [ABSTRACT FROM AUTHOR]

Introduction: Surgical coaching is utilized to enhance technical, nontechnical, and teaching skills. This study aims to evaluate the feasibility and benefit of a resident peer coaching program., Methods: Chief residents (postgraduate year 5) acted as coaches for junior residents (postgraduate year 1-3, "coachees"). All participants completed the Harvard Surgical Coaching for Operative Performance Enhancement curriculum. The coaching structure included 1) preoperative goal setting, 2) unscrubbed intraoperative observation, and 3) postoperative debrief. Upon completion, residents were surveyed to assess their experience. Descriptive and thematic analyses were performed., Results: There were 22 participants (6 coaches, 16 coachees). Five (83.3%) coaches and 14 (87.5%) coachees reported the program was useful, citing dedicated reflection outside the operating room, in-depth feedback, and structured self-assessment with increased accountability. Thirteen (81.3%) coachees reported perceived improvement in technical skills and 12 (75%) within nontechnical skills. All coaches felt they benefited and improved their ability to provide feedback. When asked how coaching compared to usual methods of operative feedback, 14 (87.5%) coachees and 5 (83.3%) coaches reported it was better, with only 1 coachee reporting it was worse. Benefits over typical operating room teaching included more feedback provided, more specific feedback, and the benefit of peer relationships. Twelve (54.5%) residents cited difficulty with coordinating sessions, but 21 (95.5%) reported that they would participate again., Conclusions: Implementation of a resident peer surgical coaching program is feasible. Both coaches and coachees perceive significant benefit with improvement in technical, nontechnical, and feedback delivery skills. Given preference over other methods of operative feedback, expansion of peer coaching programs is warranted., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Emergency general surgery (EGS) patients are at increased risk for postoperative morbidity and mortality. Obesity is a risk factor for poor outcomes in this population. Our study aimed to explore the association of body mass index (BMI) with postoperative outcomes in patients requiring common EGS procedures., Methods: A retrospective review of the 2018-2020 National Surgical Quality Improvement Program database identified patients undergoing four common EGS procedures: large bowel resection, small bowel resection, cholecystectomy, and appendectomy. Patients were classified by BMI: normal weight (18.5-24.9 kg/m 2 ), obesity classes I (30-34.9 kg/m 2 ), II (35-39.9 kg/m 2 ), III (40-49.9 kg/m 2 ), and IV (≥50 kg/m 2 ). Main outcomes of interest were major adverse event (MAE) and mortality., Results: From 2018 to 2020, a total of 82,540 patients underwent one of four common EGS procedures. On unadjusted analysis, obesity class IV had higher mortality rates compared to classes I-III (6.2% vs 3.1%, P < 0.001). Patients in obesity classes I-III had lower odds of MAE and death relative to those of normal weight. Compared to other patients with obesity, those in obesity class IV were at increased risk of MAE (odds ratio 1.27; 95% confidence interval 1.13-1.44) and death (odds ratio 1.69; 95% confidence interval 1.34-2.13)., Conclusions: Patients with varying degrees of obesity have different risk profiles following common EGS procedures. While patients in lower obesity classes had reduced odds of adverse outcomes, those with BMI ≥50 kg/m 2 were particularly at greater risk for postoperative morbidity and mortality. This vulnerable population warrants further investigation and increased vigilance to ensure high-quality care., (Published by Elsevier Inc.)

Background: While advances in diagnosis and treatment of peptic ulcer disease have led to a decrease in hospital admissions the socioeconomic distribution of these benefits is unknown., Methods: We designed a retrospective cohort study using the National Inpatient Sample from 2012 to 2013 including all patients that were admitted for peptic ulcer disease. We compared the types of ulcer related complications, the rates of intervention and the outcomes based on race and insurance status., Results: Of 42,046 patients admitted for peptic ulcer disease 80.25% had an ulcer related complication. Black patients had the lowest rates of bleeding and highest rates of perforation and were less likely to undergo surgery for their complication but mortality was not different from white patients. Uninsured patients also had lower rates of bleeding and higher rates of perforation and they were at increased risk for death., Conclusions: Unlike other surgical conditions insurance status, not race, predicts mortality in peptic ulcer disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Emergency general surgery (EGS) is an independent risk factor for morbidity and mortality, and seven procedures account for 80% of the National burden of operative EGS. We aimed to characterize the excess morbidity and mortality attributable to these procedures based on the level of procedural risk., Methods: Retrospective analysis of the ACS National Surgical Quality Improvement Project (ACS-NSQIP) database. (2005-2014). Seven EGS procedures were stratified as high risk and low risk. Primary outcomes were overall mortality, overall morbidity, major morbidity. Multivariable logistic regression was performed., Results: There were 619,174 patients identified. Comparing EGS to non-EGS in high-risk cases the OR for overall mortality was 1.39(1.33,1.45), overall morbidity 1.07 (0.98, 1.16), and major morbidity 1.15(1.03,1,27). In low-risk cases the OR for overall mortality was 1.03 (0.89, 1.19) overall morbidity 1.35 (1.23, 1.48), and major morbidity 2.18(1.90, 2.50)., Conclusions: Using a Nationally representative clinical database we identified significant heterogeneity in the outcomes of EGS depending on procedural risk. Risk stratification and benchmarking strategies need to account for the inherent heterogeneity of EGS., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Hospice improves quality and value of end of life care (EOLC), and enrollment has increased for older patients dying from chronic medical conditions. It remains unknown if the same is true for older patients who die after moderate to severe traumatic brain injury (msTBI)., Methods: Subjects included Medicare beneficiaries (≥65 years) who were hospitalized for msTBI from 2005 to 2011. Outcomes included intensity and quality of EOLC for decedents within 30 days of admission, and 30-day mortality for the entire cohort. Logistic regression was used to analyze the association between year of admission, mortality, and EOLC., Results: Among 50,342 older adults, 30-day mortality was 61.2%. Mortality was unchanged over the study period (aOR 0.93 [0.87-1.00], p = 0.06). Additionally, 30-day non-survivors had greater odds of hospice enrollment, lower odds of undergoing neurosurgery, but greater odds of gastrostomy., Conclusion: Between 2005 and 2011, hospice enrollment increased, but there was no change in 30-day mortality., (Copyright © 2018. Published by Elsevier Inc.)

Background: Aging of the population necessitates consideration of the increasing number of older adults requiring emergency care. The objective of this study was to compare outcomes and presentation of octogenarian and/or nonagenarian emergency general surgery (EGS) patients with younger adults., Methods: Based on a standardized definition of EGS, patients in the 2007 to 2011 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample were queried for primary EGS diagnoses. Included patients were categorized into older (≥80 years) vs younger (<80 years) adults based on a marked increase in mortality around aged 80 years. Using propensity scores, risk-adjusted differences in major morbidity, mortality, length of stay (LOS), and cost were compared., Results: Of 3,707,465 included patients, 17.2% (n = 637,588) were ≥80 years. Relative to younger adults, older patients most frequently presented for gastrointestinal-bleeding (odds ratio [95% confidence intervals]: 2.81 [2.79 to 2.82]) and gastrostomy care (2.46 [2.39 to 2.53]). Despite higher odds of mortality (1.67 [1.63 to 1.69]), older adults exhibited lower risk-adjusted odds of morbidity (.87 [.86 to .88]), shorter LOS (4.50 vs 5.14 days), and lower total hospital costs ($10,700 vs $12,500)., Conclusions: Octogenarian and/or nonagenarian patients present differently than younger adults. Reductions in complications, LOS, and cost among surviving older adults allude to a "survivorship tendency" to never give up, despite collectively higher mortality risk., (Copyright © 2016 Elsevier Inc. All rights reserved.)