Identifying High and Low Performing Emergency General Surgery Hospitals Using Direct Standardization

Drew W Goldberg, Rachel R Kelz, Luke Keele, Chris Wirtalla, Solomiya Syvyk
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Abstract

Importance: Variation in outcomes for emergency general surgery conditions has been shown at the hospital level. Few have examined difference across hospitals for older adults who often present with the greatest risk. To date, no one has examined differences in the outcome for those undergoing operative and nonoperative treatment. Objective: Identify high and low performing emergency general surgery (EGS) hospitals with risk-standardization to determine clinical performance differences as well as correlation between patients treated operatively and non-operatively. Design: A retrospective cohort study with 30-day outcomes. Setting: Nationwide study of acute care hospitals. Participants: Medicare beneficiaries > 65.5 years old hospitalized for an emergency general surgery condition admitted from July 1, 2015 to June 30, 2018. Exposure: Unique hospital identification. Main outcome: A composite metric of adverse event including 30- day mortality, prolonged length of stay, and readmission. Results: There were 536,284 total patients with a mean age of 74.4 +/- 12.2 years, 55% female, 84% white with average claims-based frailty index of 0.16 +/- 0.06 and mean comorbidity count of 3.57 +/- 2.46. Amongst the 1866 hospitals identified, there were 3 best performing and 11 worst performing hospitals. There were weak correlations between operative and non-operative for mortality (0.10), adverse events rates (0.21), prolonged length of stay (0.32), and readmissions (0.18) at the hospital level (all p<0.001). Conclusions and Relevance: Significant variation exists in EGS hospital performance with best ranked hospitals out-performing worst ranked hospitals on adverse event, mortality, prolonged length of stay and readmission. There is little association between patient outcomes for those treated with operative and non-operative care.
利用直接标准化识别表现优异和表现不佳的急诊普通外科医院
重要性:急诊普外科疾病的治疗结果在医院层面存在差异。但很少有人研究过老年人在不同医院的治疗效果差异,因为老年人的风险往往最大。迄今为止,还没有人研究过接受手术治疗和非手术治疗的患者的预后差异。目标:通过风险标准化确定急诊普外科 (EGS) 的高绩效医院和低绩效医院,以确定临床绩效差异以及接受手术治疗和非手术治疗的患者之间的相关性。设计:回顾性队列研究,30 天结果。研究环境:全国范围内的急症护理医院研究。参与者:2015年7月1日至2018年6月30日期间因急诊普通外科疾病住院的65.5岁医疗保险受益人>。暴露:医院唯一标识。主要结果:不良事件的综合指标,包括 30 天死亡率、住院时间延长和再入院。结果:患者总数为 536284 人,平均年龄为 74.4 +/- 12.2 岁,55% 为女性,84% 为白人,平均虚弱指数为 0.16 +/- 0.06,平均合并症为 3.57 +/- 2.46。在已确定的 1866 家医院中,有 3 家表现最佳,11 家表现最差。在医院层面,手术和非手术死亡率(0.10)、不良事件发生率(0.21)、住院时间延长率(0.32)和再入院率(0.18)之间存在微弱的相关性(均为 p<0.001)。结论与意义:EGS 医院的表现存在显著差异,在不良事件、死亡率、住院时间延长和再入院率方面,排名最好的医院优于排名最差的医院。接受手术治疗和非手术治疗的患者的预后之间几乎没有关联。
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