Hospital Operative Volume is an Essential Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients
*Robert D Becher1, *Michael P. DeWane1, *Nitin Sukumar1, *Marilyn J. Stolar1, *Thomas M. Gill1, Robert M. Becher2, Adrian A. Maung1, Kevin M. Schuster1, Kimberly A. Davis1
1Yale School of Medicine, New Haven, CT;2Park Surgical Associates, Brockton, MA
Objective: Within the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes for this demographic may require a structured system of surgical care. To study this, we sought to answer two questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing common emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume-thresholds will geriatric patients undergoing an emergency operation realize the average mortality risk?
Design: Retrospective cohort study; employed a novel use of ecological analysis with beta regression.
Setting: Acute care hospitals.
Patients: Patients (≥65years) who underwent one of ten EGS operations identified from the California State Inpatient Database (2010-2011).
Main Outcome Measures: In-hospital risk-adjusted mortality. Hospital operative volume benchmarks.
Results: 41,860 surgeries were evaluated at 299 hospitals (Table for all data). For each operation, beta regression models confirmed that mortality was significantly reduced as hospital emergency operative volume increased (p<0.001 for each). Absolute differences in mortality between the highest- and lowest-volume hospitals varied substantially. Procedure-specific hospital volume-thresholds which optimize survival varied widely, as did the percentage of hospitals meeting these benchmarks.
Conclusions: Across the spectrum of EGS, survival rates for geriatric patients were significantly improved when emergency operations were performed at hospitals with higher emergency geriatric operative volumes. Consistent with all Quality Programs of the American College of Surgeons, hospital operative volume appears to be an important metric of surgical quality for older patients undergoing emergency operations. Geriatric patients may benefit from a formal system of surgical care.
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