Cost Effectiveness of a Multidisciplinary Perioperative Protocol for High-Risk Emergency Major Abdominal Surgery in a Regional Victorian Hospital.

Background: The Australian and New Zealand Emergency Laparotomy Audit (ANZELA) was implemented as standard-of-care for Emergency Major Abdominal Surgery (EMAS) at Bendigo Health in September 2021. All EMAS patients undergo routine preoperative risk assessment (RPRA) using the 'National Emergency Laparotomy Audit (NELA) Calculator.' Patients with NELA mortality risk estimates ≥ 10% are considered 'high-risk' and routinely referred to the Intensive Care Unit (ICU) for planned postoperative admission. This study aims to identify whether RPRA and routine ICU referral for high-risk EMAS patients is a cost-effective intervention that improves postoperative outcomes in a rural health service.

Methods: This study is a retrospective audit of high-risk adult patients who underwent EMAS at Bendigo Health between September 2017 and August 2023. Postoperative outcomes and costs were compared before and after implementation of ANZELA. A cost-effectiveness analysis was subsequently conducted to estimate the additional cost required to improve postoperative outcomes and presented as incremental cost-effectiveness ratios (ICERs).

Results: A total of 191 high-risk EMAS patients were identified. The mean postoperative cost of care was AUD$52 338.78, with no significant change post-ANZELA (p = 0.983). Post-ANZELA, there was a 15.3% reduction in the rate of planned ICU admissions (p = 0.026), a 10.9% reduction in the rate of unplanned returns to theatre (p = 0.045), and a 16.83% reduction in the rate of severe postoperative complications (p = 0.03). There was no significant change in postoperative mortality (p = 0.59).

Conclusion: RPRA and routine ICU referral of high-risk EMAS improve perioperative outcomes without increasing cost-of-care. This protocol may therefore be a cost-effective tool to guide the perioperative care of EMAS patients.