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Original Investigation
May 10, 2017

Risk Associated With Complications and Mortality After Urgent Surgery vs Elective and Emergency SurgeryImplications for Defining “Quality” and Reporting Outcomes for Urgent Surgery

Author Affiliations
  • 1Department of Surgery, University of Virginia Health System, Charlottesville
JAMA Surg. Published online May 10, 2017. doi:10.1001/jamasurg.2017.0918
Key Points

Questions  Does surgery performed urgently have distinct rates of morbidity and mortality from that performed either electively or emergently?

Findings  In this nationwide cohort study of 173 643 patients who underwent general surgery, operations performed urgently had a 12.3% rate of morbidity and 2.3% rate of mortality, which were distinctly different from emergency and elective surgery.

Meaning  Because many quality metrics currently in use only distinguish emergency operations from nonemergency operations, the addition of an urgent category may improve predictive models and allow a more accurate determination of quality and value.

Abstract

Importance  Given the current climate of outcomes-driven quality reporting, it is critical to appropriately risk stratify patients using standardized metrics.

Objective  To elucidate the risk associated with urgent surgery on complications and mortality after general surgical procedures.

Design, Setting, and Participants  This retrospective review used the American College of Surgeons National Surgery Quality Improvement Program database to capture all general surgery cases performed at 435 hospitals nationwide between January 1, 2013, and December 31, 2013. Data analysis was performed from November 11, 2015, to February 16, 2017.

Exposures  Any operations coded as both nonelective and nonemergency were designated into a novel category titled urgent.

Main Outcomes and Measures  The primary outcome was 30-day mortality; secondary outcomes included 30-day rates of complications, reoperation, and readmission in urgent cases compared with both elective and emergency cases.

Results  Of 173 643 patients undergoing general surgery (101 632 females and 72 011 males), 130 235 (75.0%) were categorized as elective, 22 592 (13.0%) as emergency, and 20 816 (12.0%) as nonelective and nonemergency. When controlling for standard American College of Surgeons National Surgery Quality Improvement Program preoperative risk factors, with elective surgery as the reference value, the 3 groups had significantly distinct odds ratios (ORs) of experiencing any complication (urgent surgery: OR, 1.38; 95% CI, 1.30-1.45; P < .001; and emergency surgery: OR, 1.65; 95% CI, 1.55-1.76; P < .001) and of mortality (urgent surgery: OR, 2.32; 95% CI, 2.00-2.68; P < .001; and emergency surgery: OR, 2.91; 95% CI, 2.48-3.41; P < .001). Surgical procedures performed urgently had a 12.3% rate of morbidity (n = 2560) and a 2.3% rate of mortality (n = 471).

Conclusions and Relevance  This study highlights the need for improved risk stratification on the basis of urgency because operations performed urgently have distinct rates of morbidity and mortality compared with procedures performed either electively or emergently. Because we tie quality outcomes to reimbursement, such a category should improve predictive models and more accurately reflect the quality and value of care provided by surgeons who do not have traditional elective practices.

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