T.H. Friend1, M. Goosman1, D. Heffernan1, A. Stephen1 1Brown University School Of Medicine, Department Of Surgery, Providence, RI, USA
Introduction: The Lancet Commission on Global Surgery proposed the concept of bellwether operations as a small number of essential procedures that define the overall state of surgical care in a region. These procedures serve as an objective metric to characterize disparities in access to surgery. The extent to which acute care surgery (ACS) services bear the burden of bellwether general surgery cases in the United States, as well as the types of patients these services treat, is not known.
Methods: Retrospective review of all general surgery procedures and associated patient demographics at three academic medical centers between March 2015 and January 2024. Laparotomy, cholecystectomy, appendectomy, and incision and drainage were characterized as the four general surgery bellwether procedures. Patients were stratified by receiving care on ACS vs. non-ACS services.
Results: Among the 83,633 general surgery operations undertaken over the study period, 12.7% of cases were performed by the ACS service. Overall, the ACS service performed 35.8% of all bellweather operations, which comprised 60.1% of ACS case volume compared to 16.3% of non-ACS case volume (p<0.001). The high burden of bellwether cases performed by ACS was consistent during the study period and was not lessened as a result of the covid-19 pandemic. Demographically, ACS patients were from regions of lower income (48.1% vs 34.5%;p<0.001) and higher BIPOC density (34.9% vs 23.9%;p<0.001). ACS patients were also significantly less likely to carry private insurance (18.6% vs 27.8%;p<0.001) compared to non-ACS patients.
Conclusion: ACS services play a critical role in providing essential surgery to a largely socioeconomically disadvantaged population. Though ACS services perform fewer overall essential surgery procedures compared to non-ACS services, these procedures constitute the majority of ACS service volume. Serving the most at-risk surgical populations, ACS surgeons are thus uniquely positioned to reduce disparities in access to surgical care and improve public health if granted proper resources and support. The consistent and sizable proportion of bellwether procedures performed by these services over time warrants further ACS model expansion, training, and institutional support to maximize outcomes and reduce disparities among the most vulnerable critically ill surgical patients.