March 2023 -

March 2023
EAST Monthly Literature Review

"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee

This issue was prepared by EAST Emergency General Surgery Committee Member Uzer Khan, MD, MBBS, FACS.


Thank you to Haemonetics for supporting the EAST Monthly Literature Review.

In This Issue: Emergency General Surgery 

Scroll down to see summaries of these articles

Article 1 reviewed by Uzer Khan, MD, MBBS, FACS
Reconceptualizing high-quality emergency general surgery care: Non–mortality-based quality metrics enable meaningful and consistent assessment. Zogg CK, Staudenmayer KL, Kodadek LM, Davis KA. J Trauma Acute Care Surg. 2023 Jan 1;94(1):68-77.

Article 2 reviewed by Uzer Khan, MD, MBBS, FACS
Greater spatial access to care is associated with lower mortality for emergency general surgery. McCrum ML, Allen CM, Han J, Iantorno SE, Presson AP, Wan N. J Trauma Acute Care Surg. 2023 Feb 1;94(2):264-272.
Article 1
Reconceptualizing high-quality emergency general surgery care: Non–mortality-based quality metrics enable meaningful and consistent assessment. Zogg CK, Staudenmayer KL, Kodadek LM, Davis KA. J Trauma Acute Care Surg. 2023 Jan 1;94(1):68-77.

Traditionally mortality-centered metrics have been the mainstay of evaluating outcomes, but these markers are especially flawed including lower acuity EGS problems (e.g. cholecystitis, appendicitis). Drs. Zogg and colleagues recently presented and published their work on developing a novel set of non-mortality-based quality metrics including: Major morbidity during index admission, index hospital length of stay, ability to be discharged home, readmission within 30 days, total number of hospitalized days within 6 months by utilizing the Nationwide Readmissions Database (NRD). These admissions were cohorted according to complexity of their presenting problems and age which consisted of 40% simple adults, 14% complex adults, 40% simple older adults, and 6% complex older adults, with old being defined as ≥65.  A cluster analysis was able to stratify centers according to “best,” “average,” and “worst.” Their findings ultimately suggested that hospitals that performed well on one condition-specific quality metric tended to perform well on them all, and significant differences in cluster assignments explained more than 60% of variability between hospitals.

The authors show that meaningful benchmarking of EGS is possible. The findings of this study corroborate previous mortality-centric research while also supplementing those findings by including patients managed nonoperatively; by including quality metrics to enable assessment of low-mortality and highly heterogeneous EGS conditions; and with the identification of hospital clusters that are able to define meaningful associations with hospital-level factors. They find better risk-standardized outcomes in centers with highest volumes managing the most sick and frail.

The study suffers the standard limitations of studies based on administrative databases. There is a lack of nuanced clinical detail for these otherwise highly heterogeneous conditions, a potential for absent or misreported data, an inability to detect adverse events and outcomes outside of an inpatient setting, deficiencies in assessing changes in institutions over time, and an inability to follow-up patients beyond 180 days. Hopefully, this study allows for more nuanced conversations as institutions develop standardized metrics to follow in delivering the best possible care for their EGS patient populations, and allows for a few answers to the ‘how’ of EGS regionalization. 

Article 2
Greater spatial access to care is associated with lower mortality for emergency general surgery. McCrum ML, Allen CM, Han J, Iantorno SE, Presson AP, Wan N. J Trauma Acute Care Surg. 2023 Feb 1;94(2):264-272.

Trauma systems were developed in an effort to mitigate the adverse outcomes associated with delays in access to hemorrhage control and trauma care; however, such regional systems do not exist for EGS.  Dr. McCrum et al. assessed the impact of access to healthcare for EGS patients on various outcomes.  They considered distance to tertiary care facilities in addition to availability (provider-to-population ratios); otherwise, known as “potential spatial access” and a spatial access ratio (SPAR). This recognizes that the nearest hospital may not necessarily be able to care for a complex EGS problem. The authors queried databases from 12 states on urgent and emergent admissions (over 877,000 patients) for eight common EGS conditions (appendicitis, cholecystitis, diverticulitis, hernia, intestinal obstruction, mesenteric ischemia, pancreatitis, and peptic ulcer disease). These diagnoses were stratified as complex or uncomplicated.  SPAR values were stratified as very low (0), low (<0.5), moderate (0.5-1), and greater than average (>1). Their primary outcome was in-hospital mortality, and the secondary outcome was major morbidity (e.g. respiratory failure, VTE, or CVA, etc.). The authors found that overall mortality was 2.5% and the incidence of major morbidity was about 27% with mortality in the very low access group higher (4.4%) than the high access group (2.5%).  This finding remained consistent even after accounting for aspatial factors such as insurance status and neighborhood poverty/vulnerability. Very low access patients had a higher proportion of complex disease (2.5x greater incidence) and were less likely to be admitted to a teaching hospital, and hospitals with advanced clinical resources.  Major morbidity did not differ between the groups.

This is a database query study which is inevitably limited by the quality of the data in the database. SPAR is only a measure of potential access and does not consider the real-world issues faced by many of our patients including access to transportation, time off from work, availability of social support, and choice of hospital. The authors conclude that increasing spatial access from the lowest to average access would decrease the odds of mortality by 5%. Their goal was to provide a ‘why’ to the regionalization of EGS care – presumably, the improved access to care would present delays in implementation of definitive care and thereby lend them to present with advanced disease. Additionally, the authors contend that while improving spatial access is a clearly important goal, the real impact may well be in the development of regionalized systems for EGS similar to that which has been done for trauma. The latter may help with throughput of patients in a timely manner to the resources that they need, which this study certainly provides rationale for such an overarching goal.

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