R.C. Acker1, J.W. Rosenthal1, J. Sharpe1, E. Kaufman1, H. Wachtel1, R.R. Kelz1 1Hospital Of The University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA
Introduction:
Individual surgeons differ in the decision to operate for a given clinical condition, yielding variable surgeon-level tendency to operate (TTO). Little is known about how this variation affects patient outcomes. In emergency general surgery (EGS), patients cannot select their surgeon, meaning that surgeons are assigned in an as-if-at-random manner. The aim of this study is to evaluate the association of surgeon TTO with outcomes in EGS.
Methods:
All emergent/urgent hospitalizations with a surgical attending for adults ≥ 18 years with EGS conditions were identified in the Healthcare Cost and Utilization Project State Inpatient Database (2016-2020) in four geographically diverse states (AZ, FL, MD, NV) using validated ICD-10 codes. TTO was calculated at the surgeon level (TTO=total number of operations performed/total number of hospitalizations). Surgeons with less than 10 subjects, no operative cases, and a TTO equal to 0 or 1 were excluded. Outcomes included any 30-day readmissions, emergent 30-day readmissions, and 30-day Emergency Department (ED) revisits. Hierarchical logistic regression adjusting for 47 potential confounders and clustering at the surgeon and hospital level was used to generate predicted rates of outcomes. Subgroup analysis was performed by treatment group (operative vs. non-operative).
Results:
Overall, 4,093 surgeons operated on 231,754 out of 514,657 patients (45%). Median TTO was 0.40 [IQI 0.01,0.95]. Median patient age was 60 years [IQI 45, 74], many patients had 3 or more comorbid conditions (45%), and the most frequent indication for hospitalization was gallstone related disease (22%). The unadjusted rates of 30-day readmission, emergent readmission, and ED revisit were significantly higher for surgeons in the lowest compared to highest TTO quartile (18.2% vs. 8.8%, p<0.001; 17.2% vs. 8.4%, p<0.001; 16.5% vs. 8%, p<0.001 respectively). After adjusting for potential confounders, this pattern persisted with low TTO surgeons having significantly higher predicted rates of readmission, emergent readmission and ED revisit compared to high TTO surgeons. There were no significant differences in predicted rates among patients who received an operation. However, predicted rates of emergent readmission and ED revisit for non-operative patients was significantly higher in low TTO compared to high TTO surgeons (Figure 1: risk-adjusted outcomes).
Conclusion:
In EGS, treatment by a surgeon with a higher tendency to operate is associated with a significantly lower rate of readmission and ED revisit. This pattern is maintained among non-operative patients. This provides evidence that a surgeon’s judgement on when to operate affects their operative and non-operative patient outcomes.