Person:

Chang, David

Objective: This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care. Design: A retrospective cohort analysis of high-risk EGS admissions using GC's international administrative data set. Setting: 23 large hospitals in Australia, England and the USA. Methods: Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals. Results: 69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p<0.01) readmission (OR=1.42, p<0.01) and length of stay (OR=1.98, p<0.01) were worse in English units. Patient factors (age, pathology, comorbidity) were significantly associated with worse outcome as were structural factors, including low intensive care unit bed ratios, high volume and interhospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with shorter length of stay. Conclusions: Key factors that influence outcomes were identified. For patients who underwent surgery, outcomes were similar at 7 days but not at 30 days. This may be attributable to better infrastructure and resource allocation towards EGS in the US and Australian centres.

Importance: Lack of insurance coverage has been associated with delays in seeking care, more complicated diseases at the time of diagnosis, and decreased likelihood of receiving optimal surgical care. The Affordable Care Act’s (ACA) Medicaid expansion has increased coverage among millions of low-income Americans, but its impact on care for common surgical conditions remains unknown. Objective: To evaluate the impact of the ACA’s Medicaid expansion on access to timely and recommended care for common and serious surgical conditions. Design: Quasi-experimental difference-in-differences study design, using hospital administrative data to compare patient-level outcomes in expansion vs. non-expansion states, before (2010- 2013) versus after (2014-2015) expansion. Setting: Academic medical centers and affiliated hospitals in 27 Medicaid expansion states and 15 non-expansion states. Participants: Patients aged 18 to 64 years admitted to a study hospital between January 2010 and September 2015 with appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD) or aortic aneurysm (N=293,529). Exposure(s): State adoption of Medicaid expansion Main Outcome(s) and Measure(s): Presentation with early uncomplicated disease (diverticulitis without abscess, fistula, or sepsis; nonruptured aortic aneurysm at time of repair; and PAD without ulcerations or gangrene), and receipt of optimal management (cholecystectomy for acute cholecystitis; laparoscopic approach for cholecystectomy or appendectomy; limb- salvage for PAD). Results: Medicaid expansion was associated with a 7.5 percentage-point decreased probability of patients being uninsured (95% CI -12.2 to -2.9; P=0.002) and an 8.6 percentage-point increased probability of having Medicaid (95% CI 6.1 to 11.1; P<0.001). Medicaid expansion was associated with a 1.8 percentage-point increase in the probability of early uncomplicated presentation (95% CI 0.7 to 2.9; P=0.001), and a 2.6 percentage-point increase in the probability of receiving optimal management (95% CI 0.8 to 4.4; P=0.006). Conclusions and Relevance: The ACA’s Medicaid expansion was associated with increased insurance coverage and improved receipt of timely care for five common surgical conditions.