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Original Investigation
December 26, 2019

Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions

Author Affiliations
  • 1Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Department of Surgery, University of California at San Diego, La Jolla
  • 3Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
  • 4Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 5Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Surg. Published online December 26, 2019. doi:10.1001/jamasurg.2019.5087
Key Points

Question  Do older adults who undergo emergency general surgery have similar rates of death, postdischarge hospital use, and days at home compared with those with acute medical conditions, such as pneumonia, heart failure, and acute myocardial infarction?

Findings  In this cohort study of 481 417 matched pairs of older Medicare beneficiaries, emergency general surgery was associated with similar odds of 1-year mortality, approximately 30% lower rates of hospital use during 1 year, and similar number of days at home compared with acute medical admission. However, in both groups, 1-year mortality was 29.7% or higher; more than 56% had a hospital encounter in the year after discharge and at least 56 days away from home.

Meaning  The findings suggest that similar to hospitalizations for pneumonia, heart failure, and acute myocardial infarction, emergency general surgery in older adults may be associated with high mortality and health care utilization after discharge and should also be considered a target for policies aimed at quality improvement.

Abstract

Importance  Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement.

Objective  To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions.

Design, Setting, and Participants  This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019.

Exposures  Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction.

Main Outcomes and Measures  One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year.

Results  A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004).

Conclusions and Relevance  In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.

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