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Background Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma. Methods Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size. Results There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon. Conclusions At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management. [ABSTRACT FROM AUTHOR]

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]

Clear communication around surgical device use is crucial to patient safety. We evaluated the utility of the Device Briefing Tool (DBT) as an adjunct to the Surgical Safety Checklist. A nonrandomized, controlled pilot of the DBT was conducted with surgical teams at an academic referral center. Intervention departments used the DBT in all cases involving a surgical device for 10 wk. Utility, relative advantage, and implementation effectiveness were evaluated via surveys. Trained observers assessed adherence and team performance using the Oxford NOTECHS system. Of 113 individuals surveyed, 91 responded. Most respondents rated the DBT as moderately to extremely useful. Utility was greatest for complex devices (89%) and new devices (88%). Advantages included insight into the team's familiarity with devices (70%) and improved teamwork and communication (68%). Users found it unrealistic to review all device instructional materials (54%). Free text responses suggested that the DBT heightened awareness of deficiencies in device familiarity and training but lacked a clear mechanism to correct them. DBT adherence was 82%. NOTECHS scores in intervention departments improved over the course of the study but did not significantly differ from comparator departments. The DBT was rated highly by both surgeons and nurses. Adherence was high and we found no evidence of "checklist fatigue." Centers interested in implementing the DBT should focus on devices that are complex or new to any surgical team member. Guidance for correcting deficiencies identified by the DBT will be provided in future iterations of the tool. [ABSTRACT FROM AUTHOR]

Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system. [ABSTRACT FROM AUTHOR]

Risk prediction accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator has been shown to differ between emergency and elective surgery. Benchmarking methods of clinical performance require accurate risk estimation, and current methods rarely account for admission source; therefore, our goal was to assess whether the ACS-NSQIP predicts mortality comparably between transferred and nontransferred emergency general surgery (EGS) cases. This is a retrospective study using the ACS-NSQIP database from 2005 to 2014including all inpatients who underwent one of seven previously described EGS procedures. The admission source was classified as directly admitted versus transferred from an outside emergency room or an acute care facility. We compared the accuracy of ACS-NSQIP–predicted mortality probabilities using the observed-to-expected (O:E) ratio and Brier score. A subgroup analysis was performed to compare accuracy of high-risk and low-risk procedures. A total of 206,103 EGS admissions were identified, of which 6.97% were transfers. Overall mortality was 3.26% for the entire cohort and 10.24% within the transfer group. The O:E ratios generated by ACS-NSQIP models differed between transferred patients (O:E = 1.0, 95% confidence interval = 0.97-1.02) and nontransferred patients (O:E = 1.12, 95% confidence interval = 1.09-1.14). The Brier score for transferred patients was greater than that for nontransferred patients (0.063 versus 0.018, respectively) showing higher accuracy for nontransferred patients. The ACS-NSQIP risk estimates used for benchmarking differ between transferred and nontransferred EGS cases. Analyses of the Brier score by the ACS-NSQIP risk calculator demonstrated inferior prediction for transferred patients. This increased burden on accepting institutions will have an impact on quality metrics and should be considered for benchmarking of clinical performance. [ABSTRACT FROM AUTHOR]

Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients. [ABSTRACT FROM AUTHOR]

Abstract Background Understanding the mechanisms that lead to health-care disparities is necessary to create robust solutions that ensure all patients receive the best possible care. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing an emergency general surgery (EGS). Materials and methods Using the Florida State Inpatient Database, we analyzed patients who underwent one or more of seven EGS procedures from 2010 to 2014. The primary outcome was development of a major postoperative complication. To determine the individual surgeon effect on complications, we performed multilevel mixed effects modeling, adjusting for clinical and hospital factors, such as diagnosis, comorbidities, and hospital teaching status and volume. Results 215,745 cases performed by 5816 surgeons at 198 hospitals were included. The overall unadjusted complication rate was 8.6%. Black patients had a higher adjusted risk of having a complication than white patients (odds ratio 1.12, 95% confidence interval 1.03-1.22). Surgeon random effects, when hospital fixed effects were held constant, accounted for 27.2% of the unexplained variation in complication risk among surgeons. This effect was modified by patient race; for white patients, surgeon random effects explained only 12.4% of the variability, compared to 52.5% of the variability in complications among black patients. Conclusions This multiinstitution analysis within a single large state demonstrates that not only do black patients have a higher risk of developing a complication after undergoing EGS than white patients but also surgeon-level effects account for a larger proportion of the between-surgeon variation. This suggests that the individual surgeon contributes to racial disparities in EGS. [ABSTRACT FROM AUTHOR]

Abstract Background Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events. Methods A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR). Results There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients. Conclusions Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS. [ABSTRACT FROM AUTHOR]

Background Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR). Materials and methods We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis. Results Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation. Conclusions Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes. [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]

Background The purpose of this investigation was to delineate whether elderly patients with spinal injuries benefit from transfers to higher level trauma centers. Methods Retrospective review of the National Trauma Data Bank 2007 to 2011, including patients > 65 (y) with any spinal fracture and/or spinal cord injury from a blunt mechanism. Patients who were transferred to level I and II centers from other facilities were compared to those admitted and received their definitive treatment at level III or other centers. Results Of 3,313,117 eligible patients, 43,637 (1.3%) met inclusion criteria: 19,588 (44.9%) were transferred to level I–II centers, and 24,049 (55.1%) received definitive treatment at level III or other centers. Most of the patients (95.8%) had a spinal fracture without a spinal cord injury. Transferred patients were more likely to require an intensive care unit admission (48.5% versus 36.0%, P < 0.001) and ventilatory support (16.1% versus 13.3%, P < 0.001). Mortality for the entire cohort was 7.7% (8.6% versus 7.1%, P < 0.001) and significantly higher, at 21.7% for patients with a spinal cord injury (22.3% versus 21.0%, P < 0.001). After adjusting for all available covariates, there was no difference in the adjusted mortality between patients transferred to higher level centers and those treated at lower level centers (adjusted odds ratio [95% confidence interval]: 1.05 [0.95–1.17], P = 0.325). Conclusions Transfer of elderly patients with spinal injuries to higher level trauma centers is not associated with improved survival. Future studies should explore the justifications used for these transfers and focus on other outcome measures such as functional status to determine the potential benefit from such practices. [ABSTRACT FROM AUTHOR]

Background State-supported trauma systems have a proven association with improved mortality, but to date, there are no data reported on what mechanism leads to this benefit. Our hypothesis is that trauma systems with funding support are associated with increased number of trauma centers (TCs). Materials and methods A retrospective population study: data for the number of American College of Surgeons–verified adult TCs in 2010 were obtained from the American College of Surgeons and for state-designated TCs from state departments of health. Population and gross domestic product (GDP) were obtained from the US Census. The main outcome measure was the number of TCs per population and per GDP. Statistical analysis was carried out using the Mann–Whitney U -test and Poisson regression. Results There was no association between a trauma system and the numbers of level 1 or 2 centers. In states with funded trauma systems, the numbers of level 3 centers per GDP and per million state population were 4.76 ± 2.37/$100 billion and 1.77 ± 0.51/million people compared with 0.72 ± 1.72/$100 billion and 0.28 ± 0.60/million people for unfunded states ( P < 0.05). Poisson multivariate regression identified system funding as an independent predictor of number of level 3 centers. Conclusions Our study shows that the number of level 3 TCs significantly and independently correlated with the presence of a funded trauma system. The number of level 1 and 2 centers showed no such correlation. Further study will determine if increased number of level 3 centers leads to improved clinical outcome. [ABSTRACT FROM AUTHOR]