Abstract
Background
Hospital-level variation has been found to influence outcomes in emergency general
surgery. However, whether the individual surgeon plays a role in this variation is
unknown.
Methods
We performed an analysis of the Florida State Inpatient Database (2010–2014), which
is linked to the American Hospital Association's Annual Survey Database, including
patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis,
small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy,
or cholecystectomy). We used multilevel random effects modeling to quantify the amount
of variation in mortality, complications, and 30-day readmissions attributable to
surgeons. Patient clinical and demographic factors, as well as hospital-level factors,
were introduced into the model in a forward stepwise fashion, and the percent of the
variation attributable to surgeons was derived.
Results
Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency
general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication
and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation
had the greatest impact on mortality, explaining 32.77% of the overall variability
in mortality risk compared with 0.08% and 2.28% for complications and readmissions,
respectively. Peptic ulcer disease operations were most susceptible to surgeon-level
variation in mortality and readmissions, whereas appendectomies and cholecystectomies
were least susceptible to surgeon-level variation for all outcomes.
Conclusions
Surgeon-level variation contributes to a significant portion of mortality in EGS.
This variation is most pronounced in surgery for peptic ulcer disease, a high-risk,
low-frequency surgical condition. Programs to reduce mortality in emergency general
surgery should address reducing variability in practice with attention to high-risk,
low-frequency procedures.
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Article info
Publication history
Published online: August 30, 2018
Accepted:
July 9,
2018
Received in revised form:
July 7,
2018
Received:
April 30,
2018
Footnotes
This work was presented at the 89th Annual Scientific Meeting of the Pacific Coast Surgical Association on February 17, 2018, in Napa, CA.
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
