M. Castillo-Angeles1, D. Metcalfe2, S. L. Nitzschke1, A. H. Haider1, A. Salim1, J. M. Havens1 1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2University Of Oxford John Radcliffe Hospital,Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences,Oxford, OXFORD, United Kingdom
Introduction: Failure to rescue (FTR) is an emerging quality metric that has been shown to be sensitive to differences in healthcare quality. Racial and socioeconomic disparities have been previously described in the surgical setting, but not in a particularly high-risk population such as Emergency general surgery (EGS) patients. This study sought to evaluate for disparities in FTR within the EGS population.
Methods: This is an observational study using the National Inpatient Sample (NIS) 2012-2013; the largest all-payer inpatient database in the United States. The inclusion criteria were all inpatients that underwent one of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Outcomes were Serious Adverse Events (SAE), in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed a SAE). Logistic multivariable regression models were used to adjust for patient- (age, sex, race, payer status, Charlson comorbidity index) and hospital-level (hospital size and location) characteristics. A subgroup analysis was performed comparing the outcomes between high-risk (partial excision of large intestine, excision of small intestine, control of hemorrhage and suture of ulcer of stomach or duodenum, lysis of peritoneal adhesions and laparotomy) and low-risk (appendectomy and cholecystectomy) procedures.
Results: A weighted total of 1.1 million EGS admissions were identified; 150,000 (13.8%) developed a SAE and 15,000 died, giving an overall FTR rate of 10%. Patients with public insurance (adjusted odds ratio 1.29, 95% CI 1.24 – 1.34) and uninsured patients (aOR 1.09, 1.02-1.16) were significantly more likely to die than those with private insurance. In both the unadjusted and adjusted analyses, Black patients had higher odds of a SAE (14.9% versus 17.3%, p<0.001; adjusted odds ratio 1.39, 95% CI 1.33-1.45) when compared to White patients. However, race was not a risk factor for FTR (aOR 0.87, 0.85-1.00). Publicly insured and uninsured patients had higher odds of SAE (aOR 1.29, 1.24-1.34 and aOR 1.09, 1.02-1.16, respectively). Publicly insured patients had increased adjusted odds of FTR when compared with privately insured patients (aOR 1.31, 1.13-1.52) (Table 1). Subgroup analysis between high- and low-risk procedures showed similar results.
Conclusion: Insurance status, but not race, is an independent risk factor for FTR in a representative population of patients undergoing EGS. Race was determined a risk factor for developing SAEs. FTR partially explains worse outcomes for publicly insured and uninsured EGS patients. FTR is a complex problem and requires prospective studies for more in-depth analysis of this important quality measure.
