Risk Associated With Complications and Mortality After Urgent Surgery vs Elective and Emergency Surgery Implications for Defining "Quality" and Reporting Outcomes for Urgent Surgery
Risk Associated With Complications and Mortality After Urgent Surgery vs Elective and Emergency Surgery Implications for Defining "Quality" and Reporting Outcomes for Urgent Surgery
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DOI：
10.1001/jamasurg.2017.0918
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发表时间：
2017-08-01
期刊：
影响因子：
16.9
通讯作者：
Friel, Charles M.
中科院分区：
文献类型：
--
作者：
Mullen, Matthew G.;Michaels, Alex D.;Friel, Charles M.
重要性考虑到目前的气候结果驱动的质量报告，这是至关重要的，以适当的风险分层患者使用标准化metrics.OBJECTIVE阐明风险与紧急手术的并发症和死亡率后，普通外科手术。和参与者本回顾性研究使用美国外科医师学会国家外科质量改进计划数据库，收集所有进行的普通外科病例2013年1月1日至2013年12月31日，全国435家医院。数据分析时间为2015年11月11日至2017年2月16日。结果所有非择期和非急诊手术均被归类为急诊手术。次要结局包括30天并发症发生率，再次手术，结果173643例普通外科手术患者中，（101 632名女性和72 011名男性），130 235名（75.0%）被归类为择期，22 592名（13.0%）被归类为急诊，20 816名（12.0%）被归类为非择期和非急诊。当控制标准的美国外科医师学会国家手术质量改进计划术前危险因素时，以择期手术为参考值，3组发生任何并发症的比值比（OR）显著不同（急诊手术：OR，1.38; 95%CI，1.30-1.45; P < .001;急诊手术：OR，1.65; 95%CI，1.55-1.76; P < .001）和死亡率（急诊手术：OR，2.32; 95% CI，2.00-2.68; P < .001;急诊手术：OR，2.91; 95% CI，2.48-3.41; P < .001）。紧急进行的手术有12.3%的发病率（n = 2560）和2.3%的死亡率（n = 471）。结论和相关性这项研究强调了需要改善的危险分层的基础上的紧迫性，因为紧急进行的手术有不同的发病率和死亡率相比，无论是择期或紧急进行的程序。因为我们将质量结果与报销联系在一起，这样一个类别应该可以改善预测模型，更准确地反映没有传统选择性做法的外科医生提供的护理质量和价值。
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.