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. 2017 Aug 16;152(8):768–774. doi: 10.1001/jamasurg.2017.0918

Risk Associated With Complications and Mortality After Urgent Surgery vs Elective and Emergency Surgery

Implications for Defining “Quality” and Reporting Outcomes for Urgent Surgery

Matthew G Mullen 1, Alex D Michaels 1, J Hunter Mehaffey 1, Christopher A Guidry 1, Florence E Turrentine 1, Traci L Hedrick 1, Charles M Friel 1,
PMCID: PMC5710495  PMID: 28492821

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.


This cohort study uses data from the American College of Surgeons NSQIP to examine the risk associated with complications and mortality after urgent surgery compared with elective and emergency surgery.

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.

Introduction

Defining “quality” health care has become a major focus of the medical community, health care payers, and US Centers for Medicare & Medicaid Services (CMS). Postoperative outcome measures are increasingly being publicly reported, which has implications for hospital and physician reimbursement and reputation. In 2009, the CMS began publicly reporting 30-day rates of readmission for patients admitted to an acute care hospital for myocardial infarction, heart failure, and pneumonia. The program has since broadened to include several other outcome measures in both medical and surgical patients.

Medicare’s Physician Quality Reporting System is the largest US quality reporting program created by the CMS as part of the Affordable Care Act. In July 2007, the program began reporting measures of process quality and physiological patient outcomes and rewarding physicians who self-reported outcomes. However, in 2015 the program started imposing penalties in Medicare Part B reimbursement to physicians who fail to self-monitor and submit designated quality measures. Outcomes following many general surgical procedures, including colectomy, ventral hernia repair, appendectomy, and cholecystectomy, had previously been included, such as rates of anastomotic leak, surgical site infection, unplanned reoperation, and readmission, but are being excluded from the 2017 Medicare Value-Based Payment Modifier owing to inconsistent risk adjustment. Risk adjustment is necessary to account for the presence of comorbidities that put patients at higher risk of postoperative complications. Most risk adjustment models consider whether operations are performed emergently because the expected complication rate is substantially higher than that with elective surgery.

Patients with acute disease processes who undergo general surgery are frequently admitted for medical optimization before surgery or a trial of nonoperative conservative management. This plan commonly occurs in the management of cholecystitis, adhesive small-bowel obstruction, and acute diverticulitis. Many of these patients will undergo surgical intervention later in their hospitalization. These urgent, albeit nonemergency, operations are performed following a period of nonoperative management. Complication rates and mortality for this substantial population of patients have not been well described in the surgical literature. The purpose of this study was to elucidate the risk associated with urgent surgery on 30-day complications and mortality after general surgical procedures. We hypothesized that patients who undergo urgent surgery will have a complication and mortality profile different from those who undergo either elective or emergency surgery, which would hold important implications for quality reporting and pay-for-performance reimbursement penalties.

Methods

Data Set

Patient data for this study were obtained from the 2013 American College of Surgeons National Quality Improvement Program Participant Use File (ACS NSQIP PUF). The ACS NSQIP PUF is a nationwide, comprehensive data set designed to improve the quality of surgical care. The 2013 ACS NSQIP PUF included data for patients who underwent surgery at 435 participating hospitals between January 1, 2013, and December 31, 2013. The ACS NSQIP PUF has been designated by the University of Virginia Institutional Review Board for Health Sciences Research as a public data set; as such, this study is considered exempt from formal institutional review board review.

Patients and Variables

Emergency surgery in the ACS NSQIP is captured as part of the American Society of Anesthesiologists (ASA) Physical Status classification system, which is designated by the surgeon or anesthesiologist immediately prior to each operation. Elective surgery is defined only as procedures performed on patients who are brought to a medical facility for a scheduled (elective) surgery on the day of their operation. It specifically does not include patients who are inpatients at an acute care hospital, are transferred from an emergency department or clinic, or undergo emergency or urgent surgery. As described in the ACS NSQIP protocols, surgical clinical reviewers are specifically instructed to code “urgent” operations as nonemergency and nonelective because these cases are not true emergencies. In this article, urgent status implies that an operation was coded as nonelective and nonemergency. Cases were excluded from analysis if either variable was not known or was omitted.

Variables were selected a priori. We included all preoperative variables used by the ACS NSQIP Risk Calculator to estimate a patient’s probability of morbidity and mortality. Variables included patient age, sex, functional status, ASA class, corticosteroid use, smoking status, body mass index class, presence of ascites, sepsis, ventilator dependence, disseminated cancer, type 1 or 2 diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, dialysis dependence, and acute renal failure. In addition to emergency surgery, which is included in the ACS NSQIP Risk Calculator, urgent status was also included in the present multivariate analysis. The primary end point was patient mortality within 30 days of surgery. Secondary end points examined included 30-day rates of complications, hospital readmissions, and unplanned reoperations.

Statistical Analysis

Statistical analysis was performed from November 11, 2015, to February 16, 2017. Comparisons were made as a function of the urgency with which an operation was performed. Unadjusted comparisons stratified by urgency classification were performed using Pearson χ2 test for categorical variables and the Mann-Whitney test for nonnormally distributed continuous data. Multivariate logistic regression analysis was performed, with mortality within 30 days of an index operation as the primary outcome. Secondary outcomes included the occurrence of any complication recorded in the ACS NSQIP PUF, need for reoperation, or readmission within 30 days. All tests were 2-sided, with P < .05 considered significant. Statistical analyses were performed with SAS software, version 9.3 (SAS Institute Inc).

Results

A total of 173 643 general surgery cases met criteria for inclusion and were analyzed in this study. When operations were stratified according to urgency status, 130 235 (75.0%) were considered elective, 20 816 (12.0%) urgent, and 22 592 (13.0%) emergency. Demographic characteristics for all patients included are given in Table 1. Comparisons of preoperative variables and preoperative characteristics showed that patients who underwent elective, urgent, and emergency surgery differed for most variables with few exceptions. Table 2 provides the most common operations performed electively (laparoscopic cholecystectomy; 8420 cases [6.5%]), urgently (laparoscopic cholecystectomy; 4666 [22.4%]), and emergently (laparoscopic appendectomy; 10 305 [45.6%]). Length of stay before the operation was significantly longer for patients undergoing urgent operations (1 day [interquartile range, 0-3 days]) than for those undergoing elective surgery (0 days [interquartile range, 0-0 days]; P < .001) and those undergoing emergency surgery (0 days [interquartile range, 0-1 day]; P < .001).

Table 1. Univariate Analysis of Preoperative Patient Variables .

Preoperative Variable Surgery, No. (%) P Value
Elective
(n = 130 235)
Urgent
(n = 20 816)a
Emergency
(n = 22 592)
Age group, y
<65 91 732 (70.4) 14 281 (68.6) 16 911 (74.9) <.001
65-75 24 829 (19.1) 3323 (16.0) 2904 (12.9) <.001
75-85 11 524 (8.9)b 2432 (11.7) 2085 (9.2)b <.001
≥85 2150 (1.7) 780 (3.8) 692 (3.1) <.001
Female sex 78 522 (60.3) 11 371 (54.6) 11 739 (52.0) <.001
BMI classification
Underweight (<18.5) 2834 (2.2) 1407 (6.8) 2335 (10.3) <.001
Normal weight (18.5-24.9) 31 325 (24.1) 5824 (28.0) 6673 (29.5) <.001
Overweight (25.0-29.9) 37 537 (28.8)b 5930 (28.5)b 6451 (28.6)b .48
Obese
I (30.0-34.9) 25 069 (19.3) 3859 (18.5) 3735 (16.5) <.001
II (35.0-39.9) 14 422 (11.1) 2025 (9.7) 1793 (7.9) <.001
III (≥40.0) 19 048 (14.6) 1771 (8.5) 1605 (7.1) <.001
Independent functional status 128 475 (98.7) 19 488 (93.6) 21 546 (95.4) <.001
ASA classification
Class 1 9461 (7.3) 1681 (8.1) 4329 (19.2) <.001
Class 2 63 870 (49.0) 8306 (39.9)b 9075 (40.2)b <.001
Class 3 53 475 (41.1) 8887 (42.7) 6314 (28.0) <.001
Class 4 3429 (2.6) 1942 (9.3) 2874 (12.7) <.001
Class 5 0 0 0 NA
Chronic corticosteroid use 5338 (4.1) 1365 (6.6) 1064 (4.7) <.001
Ascites 314 (0.2) 315 (1.5) 462 (2.0) <.001
Presence of sepsis
SIRS 802 (0.6) 2481 (11.9) 3848 (17.0) <.001
Sepsis 290 (0.2) 1587 (7.6) 3449 (15.3) <.001
Septic shock 46 (0.04) 163 (0.8) 962 (4.3) <.001
Ventilator dependence 35 (0.03) 174 (0.8) 473 (2.1) <.001
Disseminated cancer 3843 (3.0) 982 (4.7) 589 (2.6) <.001
Diabetes
Type 1 6979 (5.4)b 1644 (7.9) 1198 (5.3)b <.001
Type 2 12 419 (9.5) 1727 (8.3) 1390 (6.2) <.001
Hypertension 56 683 (43.5) 8702 (41.8) 7498 (33.2) <.001
Cardiovascular event 0 0 0 NA
Congestive heart failure 341 (0.3) 346 (1.7) 267 (1.2) <.001
Dyspnea 8664 (6.7)b 1335 (6.4)b 1189 (5.3) <.001
Current smoker 20 901 (16.1) 4349 (20.9)b 4627 (20.5)b <.001
COPD 4284 (3.3) 1169 (5.6) 1055 (4.7) <.001
Hemodialysis dependent 1344 (1.0) 512 (2.5) 353 (1.6) <.001
Acute renal failure 158 (0.1) 142 (0.7) 288 (1.3) <.001

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); COPD, chronic obstructive pulmonary disease; NA, not applicable; SIRS, systemic inflammatory response syndrome.

a

Urgent surgery is defined in the Patients and Variables subsection of the Methods section.

b

Denotes no significant difference among identified groups on multiple comparison (P > .05).

Table 2. Most Common Operations for Each Category of Urgency.

Surgical Procedure No. (%)
Elective surgery (n = 130 235)
Laparoscopic cholecystectomy 8420 (6.5)
Inguinal hernia repair 6291 (4.8)
Sleeve gastrectomy 6232 (4.8)
Roux-en-Y gastric bypass 5453 (4.2)
Partial mastectomy 4860 (3.7)
Urgent surgery (n = 20 816)a
Laparoscopic cholecystectomy 4666 (22.4)
Laparoscopic appendectomy 3675 (17.7)
Partial colectomy 2829 (13.6)
Small-bowel resection 679 (3.3)
Lysis of adhesions 571 (2.7)
Emergency surgery (n = 22 592)
Laparoscopic appendectomy 10 305 (45.6)
Laparoscopic cholecystectomy 1388 (6.1)
Small-bowel resection 1093 (4.8)
Partial colectomy 1454 (6.4)
Lysis of adhesions 555 (2.5)
a

Urgent surgery is defined in the Patients and Variables subsection of the Methods section.

Unadjusted 30-day patient outcomes examined included the occurrence of any complication recorded in the ACS NSQIP PUF, mortality, unplanned reoperation, and readmission (Table 3). Surgical procedures performed urgently had a 12.3% rate of morbidity (n = 2560) and a 2.3% rate of mortality (n = 471) compared with a 13.8% rate of morbidity (n = 3114) and 3.7% rate of mortality for emergency surgery and a 6.7% rate of morbidity (n = 8718) and 0.4% rate of mortality (n = 516) for elective surgery. Multivariate logistic regression analysis was performed to determine the independent contribution of urgency status on 30-day mortality and postoperative morbidity (Table 4). When we controlled for standard ACS NSQIP 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).

Table 3. Unadjusted Incidence of 30-Day Postoperative Outcomes Stratified by Urgency Status.

30-d Outcome Urgency Status, No. (%) P Value
Elective
(n = 130 235)
Urgent
(n = 20 816)a
Emergency
(n = 22 592)
Mortality 516 (0.4) 471 (2.3) 846 (3.7) <.001
Morbidity 8718 (6.7) 2560 (12.3) 3114 (13.8) <.001
Hospital readmission 4818 (3.7) 1140 (5.5) 1435 (6.4) <.001
Unplanned reoperation 1146 (0.9) 322 (1.6) 314 (1.4) <.001
a

Urgent surgery is defined in the Patients and Variables subsection of the Methods section.

Table 4. Risk-Adjusted Odds Ratios for Factors Associated With Postoperative Mortality and Morbidity.

Variable 30-d Mortalitya Morbidityb
Wald χ2 Odds Ratio (95% CI) P Value Wald χ2 Odds Ratio (95% CI) P Value
Urgency 189.00 NA <.001 271.35 NA <.001
Elective NA 1 [Reference] NA NA 1 [Reference] NA
Urgentc 124.57 2.32 (2.00-2.68) <.001 128.26 1.38 (1.30-1.45) <.001
Emergency 172.72 2.91 (2.48-3.41) <.001 243.26 1.65 (1.55-1.76) <.001
Age group, y 190.56 NA <.001 116.73 NA <.001
<65 NA 1 [Reference] NA NA 1 [Reference] NA
65-75 72.08 1.76 (1.54-2.01) <.001 74.70 1.23 (1.17-1.30) <.001
75-85 135.51 2.31 (2.01-2.66) <.001 68.98 1.29 (1.21-1.37) <.001
≥85 122.82 3.06 (2.51-3.73) <.001 28.68 1.34 (1.20-1.49) <.001
Female sex 8.09 0.86 (0.78-0.96) .004 25.76 0.91 (0.87-0.92) <.001
BMI classification 74.35 NA <.001 38.34 NA <.001
Underweight (<18.5) 25.37 1.59 (1.33-1.90) <.001 3.08 1.08 (0.99-1.19) .08
Normal weight (18.5-24.9) NA 1 [Reference] NA NA 1 [Reference] NA
Overweight (25.0-29.9) 5.22 0.86 (0.75-0.98) .02 0.22 0.99 (0.94-1.04) .64
Obese
I (30.0-34.9) 10.78 0.77 (0.65-0.90) .001 4.03 1.06 (1.00-1.12) .04
II (35.0-39.9) 13.27 0.67 (0.55-0.83) <.001 21.95 1.176 (1.10-1.26) <.001
III (≥40.0) 10.88 0.71 (0.58-0.87) .001 0.78 0.97 (0.91-1.04) .38
Independent functional status 56.75 0.57 (0.50-0.66) <.001 112.79 0.63 (0.58-0.69) <.001
ASA classification 595.24 NA <.001 1116.32 NA <.001
1 NA 1 [Reference] NA NA 1 [Reference] NA
2 9.22 5.96 (1.88-18.85) .002 161.95 2.34 (2.05-2.67) <.001
3 35.36 31.85 (10.18-99.66) <.001 423.17 4.04 (3.53-4.61) <.001
4 58.80 87.79 (27.97-275.52) <.001 632.75 6.44 (5.57-7.45) <.001
Wound classification 21.63 NA <.001 687.18 NA <.001
Clean NA 1 [Reference] NA NA 1 [Reference] NA
Clean-contaminated 14.53 1.37 (1.17-1.62) .001 533.02 1.89 (1.79-1.99) <.001
Contaminated 17.15 1.50 (1.24-1.82) <.001 465.30 2.14 (2.00-2.30) <.001
Dirty or infected 16.98 1.51 (1.24-1.83) <.001 426.19 2.29 (2.12-2.48) <.001
Diabetes 14.24 NA <.001 21.49 NA <.001
None NA 1 [Reference] NA NA 1 [Reference] NA
Type 2 8.18 0.78 (0.66-0.93) .004 0.32 1.02 (0.96-1.08) .57
Type 1 3.61 1.16 (0.99-1.35) .06 21.42 1.17 (1.10-1.25) <.001
Sepsis 208.87 NA <.001 196.70 NA <.001
None NA 1 [Reference] NA NA 1 [Reference] NA
SIRS 60.95 2.01 (1.68-2.39) <.001 73.18 1.43 (1.31-1.55) <.001
Sepsis 57.83 2.00 (1.67-2.39) <.001 55.91 1.41 (1.29-1.54) <.001
Septic shock 190.25 4.45 (3.60-5.50) <.001 134.02 2.44 (2.10-2.84) <.001
Chronic corticosteroid use 12.29 1.33 (1.13-1.55) <.001 114.05 1.45 (1.36-1.56) <.001
Ascites 82.36 2.71 (2.19-3.37) <.001 35.28 1.59 (1.37-1.86) <.001
Ventilator dependence 10.38 1.45 (1.16-1.81) .001 3.81 0.83 (0.68-1.00) .05
Disseminated cancer 257.59 3.32 (2.870-3.85) <.001 41.43 1.28 (1.19-1.38) <.001
Hypertension 24.41 1.35 (1.20-1.52) <.001 23.08 1.11 (1.06-1.16) <.001
Congestive heart failure 8.51 1.43 (1.12-1.81) .003 4.89 1.20 (1.02-1.42) .03
Dyspnea 14.88 1.33 (1.15-1.54) <.001 13.58 1.13 (1.06-1.21) <.001
Current smoker 1.46 0.92 (0.80-1.05) .23 112.34 1.29 (1.23-1.35) <.001
COPD 19.89 1.41 (1.21-1.64) <.001 52.48 1.32 (1.23-1.42) <.001
Hemodialysis dependent 17.27 1.57 (1.27-1.94) <.001 1.23 0.92 (0.80-1.06) .27
Acute renal failure 10.02 1.55 (1.18-2.03) .002 47.42 2.02 (1.65-2.47) <.001
Relative value unit 100.51 1.02 (1.02-1.03) <.001 3482.98 1.05 (1.05-1.05) <.001

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); COPD, chronic obstructive pulmonary disease; NA, not applicable; SIRS, systemic inflammatory response syndrome.

a

For 30-day mortality, the C statistic is 0.93; Hosmer-Lemeshow test, 0.002; and Brier score, 0.01.

b

For morbidity, the C statistic is 0.79; Hosmer-Lemeshow test, <0.0001; and Brier score, 0.07.

c

Urgent surgery is defined in the Patients and Variables subsection of the Methods section.

Discussion

This study found that general surgical procedures performed urgently had a 12.3% rate of morbidity and a 2.3% rate of mortality, which are rates distinctly different from both emergency (morbidity, 13.8%; mortality, 3.7%) and elective (morbidity, 6.7%; mortality, 0.4%) surgery. To our knowledge, no prior study has elucidated rates of morbidity and mortality associated with urgent general surgery. This finding reveals important insight that the urgency of surgery is not binary, but rather that there are 3 categories, each with a distinct morbidity and mortality profile, and that surgical urgency can help predict postoperative complications independent of a patient’s preoperative comorbidities. Ultimately, urgency is a crucial consideration when performing patient risk stratification, reporting surgical outcomes, and establishing benchmarks for quality and performance under the Affordable Care Act.

The goal of pay-for-performance models is to account for quality of care and clinical outcomes in the compensation of physicians, rather than to solely reimburse for services provided. The findings in this study hold important implications for pay-for performance reimbursement, value-based programs, and surgical outcome reporting. Currently, risk stratification for the ACS NSQIP and the Physician Quality Reporting System considers preoperative comorbidities, functional status, ASA classification, and whether surgery was performed emergently. These programs do not account for urgent, nonelective operations that are not determined to be emergencies by the surgeon or anesthesiologist at the time of surgery. In this study, we found that these urgent operations are associated with substantially higher rates of complications and mortality when compared with elective surgery. Surgeons who commonly operate on an urgent basis, including many acute care and emergency general surgeons, are at risk of being penalized by the CMS in Medicare Part B value-based reimbursement. These surgeons may even unfairly be labeled as poor performers by current outcome reporting guidelines.

Several prior investigators have demonstrated increased rates of complications and mortality after emergency surgery. Mortality following emergency gastrointestinal surgery has been found to be as much as 5 times greater than for elective gastrointestinal surgery. This difference has previously been attributed to patient comorbidities and physiological derangements associated with acute disease processes. However, Havens et al recently demonstrated that increased morbidity and mortality following emergency general surgery is independent of preoperative comorbidities and physiological status. Our multivariate analysis demonstrated similar results: complication rates were higher in patients who underwent urgent surgery compared with those who underwent elective surgery, independent of other preoperative risk factors. Consistent with prior studies, we found that patients with preoperative comorbidities, obesity, rising ASA classification, age greater than 65 years, and contaminated surgical wounds are at an increased risk of morbidity and mortality. Current smokers were not found to be at greater risk of mortality following surgery, but smoking was predictive of postoperative complications.

Patients undergoing urgent surgery had the highest rates in our cohort of congestive heart failure, chronic obstructive pulmonary disease, diabetes, preoperative hemodialysis, chronic corticosteroid use, and disseminated cancer. Coupled with the fact that patients undergoing urgent operations have a longer preoperative length of stay, this finding suggests that patients with serious preoperative comorbidities who present with acute surgical issues may be having operative care delayed, presumably for medical optimization or following a failed trial of nonoperative management. A delay in surgical intervention could be contributing to the observed increase in morbidity and mortality. For instance, cholecystitis initially treated with antibiotics and medical optimization can progress, leading to perforation, or a small-bowel obstruction that is initially managed nonoperatively may develop ischemia. Delay in surgery for both of these conditions may result in worse pathologic conditions and the need for a more extensive operation. The prevalence of systemic inflammatory response syndrome, sepsis, and septic shock were greatest in patients undergoing emergency surgery, which would tip the risk to benefit ratio toward more expeditious surgery.

Limitations

This study has some notable limitations. First, these analyses are limited by the retrospective study design. Although the ACS NSQIP is a large national data set, its data are limited to participating hospitals, which are primarily academic medical centers. Next, surgical urgency was determined based on variables recorded in the ACS NSQIP, which is subject to anesthesiologist and surgeon discretion at the time of an operation, as well as to documentation error. Cardiac risk factors, including the presence of coronary artery disease, and history of cardiac events were not recorded in the 2013 ACS NSQIP PUF. We sought to identify trends among a large population of patients, so all general surgical procedures were included for this study; therefore, there is a lack of granularity that may make generalization of these findings to specific procedures difficult.

Conclusions

At a time when reimbursement is contingent on value-based outcomes reporting and performance, it is imperative to ensure that appropriate risk adjustment is performed. We have identified operative urgency as a key consideration for patient risk stratification. If this issue is not recognized, quality outcome reporting and value-based reimbursement will continue to incentivize operating on an elective basis and will make surgeons more reluctant to operate on patients who urgently require care.

References


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