Abstract
BackgroundThis paper assesses variation in rates of emergency surgery (ES) amongst emergency admissions to hospital in patients with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia, and intestinal obstruction.MethodsRecords of emergency admissions between 1 April 2010 and 31 December 2019 for the five conditions were extracted from Hospital Episode Statistics for 136 acute National Health Service (NHS) trusts in England. Patients who had ES were identified using Office of Population Censuses and Surveys (OPCS) procedure codes, selected by consensus of a clinical panel. The differences in ES rates according to patient characteristics, and unexplained variations across NHS trusts were estimated by multilevel logistic regression, adjusting for year of emergency admission, age, sex, ethnicity, diagnostic subcategories, index of multiple deprivation, number of co-morbidities, and frailty.ResultsThe cohort sizes ranged from 107 325 (hernia) to 268 253 (appendicitis) patients, and the proportion of patients who received ES from 11.0 per cent (diverticular disease) to 92.3 per cent (appendicitis). Older patients were generally less likely to receive ES, with adjusted odds ratios (ORs) of ES for those aged 75–79 versus those aged 45–49 years: 0.34 (appendicitis), 0.49 (cholelithiasis), 0.87 (hernia), and 0.91 (intestinal obstruction). Patients with diverticular disease aged 75–79 were more likely to receive ES than those aged 45–49 (OR 1.40). Variation in ES rates across NHS trusts remained after case mix adjustment and was greatest for cholelithiasis (trust median 18 per cent, 10th to 90th centile 7–35 per cent).ConclusionFor patients presenting as emergency hospital admissions with common acute conditions, variation in ES rates between NHS trusts remained after adjustment for demographic and clinical characteristics. Age was strongly associated with the likelihood of ES receipt for some procedures.
Highlights
Emergency surgery (ES) poses a considerable global burden to publicly funded health systems[1], and is responsible for approximately 750 000 admissions per year in England alone[2], with surgical procedures accounting for approximately 10 per cent of the annual National Health Service (NHS) budget[3]
For patients presenting as emergency hospital admissions with common acute conditions, variation in emergency surgery (ES) rates between NHS trusts remained after adjustment for demographic and clinical characteristics
The number of patients who were eligible as emergency admissions were: 107 325, 137 744, 139 090, 241 626, and 268 253 (Table S4)
Summary
Emergency surgery (ES) poses a considerable global burden to publicly funded health systems[1], and is responsible for approximately 750 000 admissions per year in England alone[2], with surgical procedures accounting for approximately 10 per cent of the annual National Health Service (NHS) budget[3]. For common acute conditions (for example, acute diverticular disease) that present as emergency admissions, an area of ongoing concern is which patients should receive ES versus nonemergency surgery (NES) strategies that include medical management, non-surgical procedures (for example, drainage of abscess), and surgery deferred to the elective (planned) setting. For patients with acute conditions, ES rates have declined over the last two decades[5], which may reflect changes in the characteristics of those presenting as emergency admissions and improved diagnostics. This paper assesses variation in rates of emergency surgery (ES) amongst emergency admissions to hospital in patients with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia, and intestinal obstruction
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