Hospital Variation in Geriatric Surgical Safety for Emergency Operation

Authors

Robert D. Becher, Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT. Electronic address: robert.becher@yale.edu.Follow
Nitin Sukumar, Yale Center for Analytical Sciences Yale School of Public Health, New Haven, CT.Follow
Michael P. DeWane, Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.Follow
Marilyn J. Stolar, Yale Center for Analytical Sciences Yale School of Public Health, New Haven, CT.Follow
Thomas M. Gill, Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT.Follow
Kevin M. Schuster, Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.Follow
Adrian A. Maung, Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.Follow
Cheryl K. Zogg, Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.
Kimberly A. Davis, Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.Follow

Document Type

Article

Publication Title

Journal of the American College of Surgeons

Abstract

BACKGROUND: The American College of Surgeons maintains that surgical care in the US has not reached optimal safety and quality. This can be driven partially by higher-risk, emergency operations in geriatric patients. We therefore sought to answer 2 questions: First, to what degree does standardized postoperative mortality vary in hospitals performing nonelective operations in geriatric patients? Second, can the differences in hospital-based mortality be explained by patient-, operative-, and hospital-level characteristics among outlier institutions? STUDY DESIGN: Patients 65 years and older who underwent 1 of 8 common emergency general surgery operations were identified using the California State Inpatient Database (2010 to 2011). Expected mortality was obtained from hierarchical, Bayesian mixed-effects logistic regression models. A risk-adjusted hospital-level standardized mortality ratio (SMR) was calculated from observed-to-expected in-hospital deaths. "Outlier" hospitals had an SMR 80% CI that did not cross the mean SMR of 1.0. High-mortality (SMR >1.0) and low-mortality (SMR <1.0) outliers were compared. RESULTS: We included 24,207 patients from 107 hospitals. SMRs varied widely, from 2.3 (highest) to 0.3 (lowest). Eleven hospitals (10.3%) were poor-performing high-SMR outliers, and 10 hospitals (9.3%) were exceptional-performing low-SMR outliers. SMR was 3 times worse in the high-SMR compared with the low-SMR group (1.7 vs 0.6; p < 0.001). Patient-, operation-, and hospital-level characteristics were equivalent among outlier-hospitals. CONCLUSIONS: Significant hospital variation exists in standardized mortality after common general surgery operations done emergently in older patients. More than 10% of institutions have substantial excess mortality. These findings confirm that the safety of emergency operation in geriatric patients can be significantly improved by decreasing the wide variability in mortality outcomes.

First Page

966

Last Page

973.e10

DOI

10.1016/j.jamcollsurg.2019.10.018

Publication Date

6-1-2020

Recommended Citation

Becher, Robert D.; Sukumar, Nitin; DeWane, Michael P.; Stolar, Marilyn J.; Gill, Thomas M.; Schuster, Kevin M.; Maung, Adrian A.; Zogg, Cheryl K.; and Davis, Kimberly A., "Hospital Variation in Geriatric Surgical Safety for Emergency Operation" (2020). Surgery. 45.
https://scholar.bridgeporthospital.org/surgery/45

Identifier

32032720 (pubmed); NIHMS1569808 (mid); PMC7409563 (pmc); 10.1016/j.jamcollsurg.2019.10.018 (doi); S1072-7515(20)30117-4 (pii)