N. L. Bandy1, S. DeShields1, R. C. Britt1 1Eastern Virginia Medical School,Norfolk, VA, USA
Introduction:
While emergency general surgical services are needed across hospitals of all sizes, workforce issues, access disparities, lifestyle considerations and hospital availability all influence the availability of timely and quality care for those in need of urgent surgical intervention. The Acute Care Surgery (ACS) model has emerged as a potential solution to improving care delivery. Prior studies have demonstrated improvements in single centers in the delivery of quality and efficient care using the ACS model. This study examines the differences in outcomes for appendicitis and cholecystitis statewide between traditional and ACS models.
Methods:
The VHI administrative database was queried to obtain outcome data on patients admitted with appendicitis or acute cholecystitis in the state of Virginia between 2008 and 2014. Hospital administration was contacted to determine surgical care model status. Data regarding length of stay, costs, complications and mortality were obtained for 28, 948 encounters. Bivariate and multivariate analysis was used to compare the outcomes between the two models.
Results:
Overall, the patients cared for with by ACS were more likely to be uninsured and with higher rates of medical co-morbidities. In the appendicitis subgroup, the patients cared for in an ACS institution had an uninsured rate of nearly 29%, versus 19% in the traditional hospitals. The ACS group had statistically higher rates of cancer and diabetes as well as renal, cardiac, liver and pulmonary disease. In the ACS hospitals, there were higher costs ($30,060 vs $28,460, p= 0.013), longer lengths of stay (3.31 vs 2.92 days, p <0.001), complications (OR 1.2, p=0.016) and overall mortality (OR 2.4, p=0.029). On multivariate analysis the mortality difference was not significant. For patients in the acute cholecystitis group, those cared for in an Acute Care Surgical hospital were more likely to be uninsured (18 vs 12.2%, p < 0.001) with higher rates of cancer, cardiovascular, renal and hepatic disease. The ACS patients had a slightly longer length of stay (4.55 vs 4.13 days, p= .009) without significant differences in mortality, complications or cost. On multivariate analysis there were no significant differences in the groups.
Conclusion:
We have demonstrated that in Virginia ACS take care of sicker patients with a higher rate of medical co-morbidities and uninsured status. For appendicitis, the outcomes are slightly worse for the ACS programs. For cholecystitis, the outcomes are equivalent at both traditional and Acute Care programs despite the differences in patient populations. This study is discordant to previously published studies demonstrating improvements following adoption of the ACS model, however prior studies only included single institutions. Further studies will be useful to determine what patient population and disease processes benefit the most from being cared for under the Acute Care model.
