Nonoperative Management in Emergency General Surgery: Does It Matter for Surgical Quality Benchmarking in Older Adults?

Abstract

Objective: We aimed to assess the association between hospital operative-to-nonoperative management ratio (ONR) and home discharge for older adults undergoing Emergency General Surgery (EGS).

Summary background data: There is an increasing number of patients being managed nonoperatively, particularly older adults, which have often been excluded from quality benchmarking. The ONR might serve as a better marker of hospital quality, instead of the traditional morbidity/mortality, which do not fully capture institutional practice patterns nor what matters most to older adults (ie, their ability to return home).

Methods: This was a retrospective analysis of the National Inpatient Sample database (2015-2018). For each hospital, we calculated a risk-adjusted ONR for adults >=65 years with common EGS diagnoses (diverticulitis, bowel obstruction, acute pancreatitis, peptic ulcer, ischemic bowel, appendicitis, and cholecystitis) who underwent urgent/emergent surgery within 48 hours. Hospital operative volume was also calculated to serve as comparison to ONR. Both metrics were then divided into tertiles. Our primary outcome was home discharge. Multivariable regression analyses evaluated the impact of ONR/Operative volume on our main outcome.

Results: Among 1,470,114 EGS admissions, 207,270 (14.1%) older adults underwent EGS. The mean ONR was 0.28 (SD 0.07). After adjusted analysis, care at hospitals within the highest ONR tertile was significantly associated with higher odds of home discharge (OR 1.10, 95% CI: 1.06-1.14). Hospital operative volume was not associated with discharge to home.

Conclusions: An increased hospital operative-to-nonoperative management ratio of EGS conditions in the geriatric population is strongly associated with increased odds of a favorable discharge home.