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To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses. A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.
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ORIGINAL ARTICL E
Incremental Cost of Emergency Versus Elective Surgery
Adil H. Haider, MD, MPH,Augustine Obirieze, MBBS, MPH,Catherine G. Velopulos, MD, MHS,
Patrick Richard, PhD,§Asad Latif, MD, MPH,|| Valerie K. Scott, MSPH,Cheryl K. Zogg, MSPH, MHS,
Elliott R. Haut, MD,David T. Efron, MD,Edward E. Cornwell III, MD,Ellen J. MacKenzie, PhD,∗∗
and Darrell J. Gaskin, PhD∗∗
Objective: To determine hospital costs and the adjusted risk of death associ-
ated with emergent versus elective surgery.
Background: Emergency surgery has a higher cost and worse outcomes com-
pared with elective surgery. However, no national estimates of the excess
burden of emergency surgery exist.
Methods: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were
analyzed. Patients aged 18 years or older who underwent abdominal aortic
aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm
were included. Using generalized linear models with propensity scores, cost
differences for emergent versus elective admission were calculated for each
procedure. Multivariable logistic regression was performed to investigate the
adjusted odds of mortality comparing elective and emergent cases. Discharge-
level weights were applied to analyses.
Results: A total of 621,925 patients, representing a weighted population
of 3,057,443, were included. The adjusted mean cost difference for emer-
gent versus elective care was $8741.22 (30% increase) for abdominal aortic
aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft,
and $7813.53 (53% increase) for colon resection. If 10% of the weighted
estimates of emergency procedures had been performed electively, the cost
benefit would have been nearly $1 billion, at $996,169,160 (95% confidence
interval [CI], $985,505,565–$1,006,834,104). Elective surgery patients had
significantly lower adjusted odds of mortality for all procedures.
Conclusions: Even a modest reduction in the proportion of emergent proce-
dures for 3 conditions is estimated to save nearly $1 billion over 10 years. Pre-
venting emergency surgery through improved care coordination and screening
offers a tremendous opportunity to save lives and decrease costs.
Keywords: cost, elective, emergency, mortality, surgery
(Ann Surg 2015;262:260–266)
Rising costs pose a serious threat to the economic viability of
the United States health care system. In 2011, US health care
expenditures reached $2.7 trillion,1and these expenses are increasing
From the Center for Surgery and Public Health, Brigham and Women’s Hospital,
Harvard Medical School & Harvard School of Public Health, Boston, MA;
Department of Surgery, Howard University College of Medicine, Washington,
DC; Center for Surgical Trials and Outcomes Research, The Johns Hopkins
School of Medicine, Baltimore, MD; §Department of Preventive Medicine &
Biometrics (PMB), Uniformed Services University,Bethesda, MD; ||Armstrong
Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore,
MD; and ∗∗Department of Health Policy and Management, The Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD.
Disclosure: None of the authors has any conflicts of interest. Sources of funding
include the National Institutes of Health/NIGMS K23GM093112-01 and the
American College of Surgeons C. James Carrico Fellowship for the study of
Trauma and Critical Care and Hopkins Center for Health Disparities Solutions
(Dr Haider).
Reprints: Adil H. Haider, MD, MPH, Center for Surgical Trials and Outcomes Re-
search, Department of Surgery, The Johns Hopkins School of Medicine, 1800 N
Orleans St, Zayed 6107, Baltimore, MD 21287. E-mail: ahaider1@jhmi.edu.
Copyright C2014 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/14/26202-0260
DOI: 10.1097/SLA.0000000000001080
at twice the rate of the gross domestic product. Nearly 30% of these
costs are related to surgical care, with projections for a 60% increase
to more than $900 billion in surgical expenditures by 2025.2
Several strategies have been adopted to curb costs and improve
surgical quality and outcomes, including global reimbursement pack-
ages with bundled payments,3pay-for-performance measures, and
incentives to decrease hospital readmission rates. One important con-
tributor to increased hospital costs and worse surgical outcomes is
the performance of emergency, rather than elective, surgery. It is well
known that an elective operation has better outcomes and lower costs
compared with the same procedure performed emergently.4–10
Emergency surgery can be prevented for many conditions
through better access to primary care and screening services. Unfor-
tunately, referral patterns for surgery vary widely across the United
States, with factors such as payer status, region, age, sex, obesity,
comorbidities, and health care provider networks significantly in-
fluencing timely access to surgical care.11,12 These variations may
contribute to well-documented health care disparities in surgical out-
comes among minority and low socioeconomic status patients. For
instance, access to subspecialty services and nonemergency admis-
sion to high-quality hospitals is worse among primary care physicians
who care for predominantly minority populations.13
Strategies that better align primary care, screening programs,
and surgical intervention to decrease the proportion of emergent ver-
sus elective surgery may be the next major opportunity to improve sur-
gical outcomes and decrease costs. The Affordable Care Act (ACA),
in fact, mandates that participating plans in the new marketplace
provide several preventive services rated A or B by the US Preven-
tive Services Task Force without requiring a co-pay/coinsurance.14,15
These directly address screening and intervention for the following
3 potentially surgical diseases: abdominal aortic aneurysm (AAA),
colorectal cancer, and heart disease.
Currently, no national estimates of the burden of emergency
surgery exist. This study determines hospital costs for the emergent
and elective treatment of 3 major surgeries—AAA repair, coronary
artery bypass graft (CABG), and colon resection for neoplasm—
which could be affected by increased access to preventive care and
screening, and estimates the cost savings that could be achieved at a
national level if a modest proportion (10%) of emergent surgical pa-
tients had received their procedure electively. In addition, the adjusted
risk of death associated with emergent versus elective procedures for
these 3 conditions is calculated. Quantifying the potential health and
economic benefits of elective versus emergency surgery is a key step
toward improving quality of care, and the solvency and effectiveness
of our health care system.
METHODS
Data Source
The Nationwide Inpatient Sample (NIS) database is the largest
all-payer inpatient care database that is publicly available in the United
States. The data are a 20% stratified sample of discharges from US
hospitals, representing 95% of the US population, which is weighted
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260 |www.annalsofsurgery.com Annals of Surgery rVolume 262, Number 2, August 2015
Annals of Surgery rVolume 262, Number 2, August 2015 Cost of Emergency Versus Elective Surgery
to permit researchers to calculate national population estimates.16 The
Nationwide Inpatient Sample subfiles, including the hospital weight
and cost-to-charge ratio (CCR) files, were merged to the core file
to obtain information on cost, hospital characteristics, and patient-
level data.17 Data from 2001 through 2010 were queried. Over this
10-year period the number of states contributing to the NIS has grown,
such that in 2010 only 4 states (Delaware, North Dakota, Idaho, and
Alabama) and the District of Columbia did not participate in the NIS.
As mentioned above, the NIS sampling strategy ensures that each
year of data presents a nationally representative sample.
Study Population
Three common surgical procedures that treat major causes of
morbidity and mortality in the United States, cardiovascular disease
and cancer, wereselected. Inter national Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) procedure codes were
used to identify patients aged 18 years or older who had undergone
AAA repair (ICD-9-CM codes 39.71, 39.73, 39.54, 38.44, 38.45,
38.46), coronary artery bypass graft (CABG) (36.1x), or colon re-
section for neoplasm, including cecectomy (45.72, 17.32), transverse
colon resection (45.74, 17.34), left hemicolectomy (45.75, 17.35),
right hemicolectomy (45.73, 17.33), and sigmoidectomy (45.76,
17.36). Patients with primary or secondary diagnosis of trauma
(ICD-9-CM codes 800-959) were excluded. Patientrecords with miss-
ing information on cost and other variables of interest were excluded.
The final study cohort included 621,925 discharge records.
Definitions
The primary outcome variable was associated with costs in-
curred for the hospital stay, calculated by multiplying total charge
by the hospital-specific all-payer CCR. Hospital-specific CCRs are
developed using standardized information on all-payer inpatient cost
and charge reported by hospitals to the Centers for Medicare and
Medicaid. The independent variable of interest was type of admis-
sion. Patients were grouped as emergent (including those coded as
urgent) or elective admission. Other information retrieved included
patient demographics, median household income of residence zip
code, primary diagnosis (using ICD-9-CM codes on first diagno-
sis position), hospital characteristics, area wage index, length of
stay, comorbidities (using the Charlson Comorbidity Index),18–20 and
mortality.
Statistical Analyses
Univariate and bivariate analyses were performed to provide
descriptive statistics. On bivariate analyses, the Pearson χ2test was
used to test distribution of categorical variables, whereas the Student
ttest was used to test difference in means. Given the likely differ-
ences in characteristics between emergently and electively admitted
patients, propensity scoring21 was used to assess the probability of
being emergently versus electively admitted, adjusting for age, sex,
race/ethnicity, primary payer, the Charlson Comorbidity Index, in-
come quartile of residential zip code, and primary diagnosis. The
incremental cost between elective and emergent patients was esti-
mated using generalized linear models with log link (to derive arith-
metic means) and gamma family (given the skewed distribution of
the costs data). These models adjusted for the above propensity score
quintiles and year of admission, local wage index, inpatient death,
hospital’s bed size, rural/urban location, hospital ownership, teach-
ing status, and US state. Using appropriate consumer price indices,
costs in prior years (2001–2009) were then adjusted for inflation and
converted to 2010 US dollars.
Estimates of mean per-patient costs for emergent and elective
admissions of AAA repair, CABG, and colon resection for neoplasm,
together with corresponding mean cost differences, were derived.
Healthcare Cost and Utilization Project-NIS discharge-level weights
were applied to all fitted models to derive national patient estimates.
Subset analyses were performed separately on records of patients aged
18 to 64 years and those 65 years or older to further assess potential
cost differences in these subgroups. Using national (weighted) esti-
mates of numbers of cases and the mean cost differences calculated
previously, the cost savings that would accrue if 10% of emergent
procedures were performed electively were then calculated.
The association between admission status and mortality was
also investigated by performing logistic regression, adjusting for
propensity score quintiles, discharge year, hospital bed size, teach-
ing status, rural versus urban location, and ownership/control. All
statistical analyses were performed using STATA/MP version 11.0
(StataCorp LP, College Station, TX). Statistical significance was de-
fined as P<0.05.
RESULTS
The final study cohort included 621,925 patients, representing
a weighted population of 3,057,443. The majority of these patients
(61.5%) underwent CABG, whereas 26.1% had colon resections for
neoplasms and 12.4% had AAA repairs. Tables 1 and 2 show the
patient and hospital characteristics of those who underwent emer-
gent or elective AAA repair, CABG, or colon resection for neoplasm.
Among patients who underwent AAA repair and colon resection
for neoplasm, 73% and 70% were performed electively, respectively,
whereas only 46% of CABG patients wereadmitted electively.The top
3 primary diagnoses for patients who underwent AAA repair were
AAA without mention of rupture (73.3%), ruptured AAA (7.2%),
and thoracic aortic aneurysm (without mention of rupture) (4.7%).
Coronary atherosclerosis of native artery (71.5%), subendocardial
infarction (first episode of care) (14.2%), and acute myocardial in-
farction of the inferior wall (3.0%) were the 3 most frequent primary
diagnoses for patients undergoing CABG. Among patients who un-
derwent colon resection, 77.4% had a malignant and 19.7% a benign
neoplasm of colon. Missing data across the data set were low, ranging
between 0.05% and 2% for various variables included in the models.
After adjusting for potential confounding factors, and
propensity score quintiles, in the generalized linear models, patients
undergoing emergent procedures had $7383.74 (95% confidence
interval [CI], 7304.70–7462.79) higher mean per-patient hospi-
talization costs compared with elective patients, representing a
29% increase. The mean cost difference was $8741.22 (95% CI,
8597.60–8884.84; 30% increase) for AAA repair, $5309.78 (95%
CI, 5234.42–5385.14; 17% increase) for CABG, and $7813.53
(95% CI, 7746.33–7880.72; 53% increase) for colon resection for
neoplasm (Fig. 1). Subset analyses were performed for patients aged
18 to 64 years and those 65 years or older, and similarly higher
associated costs were noted for emergency surgery (Table 3).
Expected cost benefits were calculated in the scenario that 10%
of emergent procedures had been performed electively. Among pa-
tients who underwent AAA repair, CABG, and colon resection for
neoplasm, this would result in $89,181,422 (95% CI, 87,716,154–
90,646,691), $535,522,640 (95% CI, 527,922,140–543,123,141), and
$186,395,664 (95% CI, 184,792,575–187,998,516) in accrued cost
savings, respectively (Table 4). On a national level, if 10% of the
weighted estimates of patients who underwent emergency proce-
dures had instead been performed electively, the associated cost ben-
efits were nearly $1 billion at $996,169,160 (95% CI, 985,505,565–
1,006,834,104).
Across all surgery categories, and overall, patients undergoing
surgery after elective admissions had significantly lower adjusted
odds of mortality (odds ratio [OR] [95% CI]: 0.45 [0.43–0.47]; 0.32
[0.29–0.35]; 0.71 [0.67–0.75]; and 0.32 [0.29–0.34]) for all patients,
AAA repair, CABG, and colon resection for neoplasm, respectively)
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C
2014 Wolters Kluwer Health, Inc. All rights reserved. www.annalsofsurgery.com |261
Haider et al Annals of Surgery rVolume 262, Number 2, August 2015
TABLE 1. Patient Characteristics
Overall AAA Repair CABG Colon Resection
(n =621,925) (n =76,878) (n =382,605) (n =162,442)
Emergent Elective Emergent Elective Emergent Elective Emergent Elective
274,512 (44) 347,413 (56) 20,725 (27) 56,153 (73) 205,188 (54) 177,417 (46) 48,599 (30) 113,843 (70)
Age group, yr, %
<25 0.05 0.06 0.25 0.14 0.01 0.01 0.16 0.11
25–39 1.33 0.92 1.87 0.65 1.10 0.71 2.10 1.38
40–59 27.85 23.18 13.67 8.19 31.23 28.39 19.66 22.46
60–79 56.64 62.16 62.76 69.94 58.08 63.31 47.91 56.53
80 14.12 13.67 21.45 21.08 9.58 7.58 30.17 19.52
Sex, %
Male 66.08 66.21 72.70 78.70 70.39 74.11 45.05 47.82
Female 33.92 33.79 27.30 21.44 29.61 25.89 54.97 52.18
Race, %
White 59.00 60.78 62.71 67.90 58.92 58.77 57.73 60.41
Black 6.04 4.50 6.36 2.73 5.10 3.50 9.87 6.94
Hispanic 4.18 3.36 3.26 2.04 4.19 3.79 4.57 3.35
Other 30.78 31.38 27.67 27.33 31.79 33.94 27.83 29.30
Charlson Index, %
0 14.59 21.19 1.25 1.25 18.08 29.18 5.51 18.58
1 29.38 27.44 38.17 39.65 34.77 36.34 2.86 7.53
2 56.03 51.37 60.57 59.10 47.14 34.48 91.63 73.89
Income quartile, %
Lowest 20.70 18.81 21.21 18.18 20.23 19.49 22.48 18.07
Second 25.22 25.26 25.45 25.84 25.29 25.43 24.83 24.72
Third 24.53 25.47 25.04 26.02 24.53 25.06 24.31 25.84
Highest 26.93 28.39 25.44 27.96 27.24 27.72 26.27 29.64
Unknown 2.62 2.07 2.86 2.00 2.71 2.30 2.12 1.74
AAA, abdominal aortic aneurysm; CABG, coronary artery bypass graft.
TABLE 2. Payer Status and Hospital Characteristics
Overall AAA Repair CABG Colon Resection
(n =621,925) (n =76,878) (n =382,605) (n =162,442)
Emergent Elective Emergent Elective Emergent Elective Emergent Elective
274,512 (44) 347,413 (56) 20,725 (27) 56,153 (73) 205,188 (54) 177,417 (46) 48,599 (30) 113,843 (70)
Primary payer, %
Private 32.55 34.75 22.38 20.87 35.47 39.08 24.54 34.83
Medicare 54.82 58.73 68.14 75.31 51.08 52.62 64.93 60.08
Medicaid 5.32 2.84 3.93 1.56 5.53 3.64 5.03 2.22
Self pay/no charge 7.13 3.54 5.43 2.17 7.72 4.47 5.37 2.76
Unknown 0.19 0.14 0.12 0.09 0.21 0.19 0.13 0.10
Hospital region, %
Northeast 16.70 15.39 18.15 18.09 16.25 12.51 18.01 18.55
Midwest 25.29 27.99 25.12 27.52 25.17 28.51 25.87 27.40
South 43.05 40.40 39.40 38.34 43.79 42.72 40.46 37.59
West 14.96 16.22 17.33 16.05 14.55 16.12 15.66 16.46
Hospital bed size, %
Small 6.96 8.06 7.59 7.79 5.79 6.39 11.67 10.80
Medium 17.99 20.25 16.66 17.92 16.54 18.50 24.69 24.12
Large 75.04 71.69 75.75 74.28 77.67 75.11 63.64 65.08
Hospital teaching status, %
Non 44.20 47.37 39.17 41.61 40.41 43.99 62.32 55.48
Teaching 55.80 52.63 60.83 58.39 59.59 56.01 37.68 44.52
Hospital location, %
Rural 6.41 7.38 5.75 5.33 4.29 4.65 15.61 12.65
Urban 93.59 92.62 94.25 94.67 95.71 95.35 84.39 87.35
AAA, abdominal aortic aneurysm; CABG, coronary artery bypass graft.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
262 |www.annalsofsurgery.com C
2014 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery rVolume 262, Number 2, August 2015 Cost of Emergency Versus Elective Surgery
compared with emergent patients. Bivariate analysis also revealed a
significantly lower mean hospital length of stay for elective patients
(6.9 ±5.8 vs 10.6 ±7.9; 5.2 ±6.8 vs 11.1 ±11.9; 7.4 ±5.6 vs 10.3 ±
7.4; and 6.9 ±5.2 vs 11.9 ±7.8 days for all patients, AAA repair,
CABG, and colon resection for neoplasm, respectively; P<0.05 for
all).
FIGURE 1. Cost differences.
DISCUSSION
This study of more than half a million patients over a 10-year
period demonstrates significant differences in mortality and costs
for the same operation performed electively versus emergently. The
incremental cost for an emergent versus elective surgical interven-
tion was between $5000 and $8500 per patient. Even a modest re-
duction of 10% in the proportion of emergency surgeries for just 3
common procedures—AAA repair, CABG, and colon resection for
neoplasms—translates into a cost benefit of nearly $1 billion over a
10-year period. In addition, mortality was significantly higher among
emergent patients, with adjusted ORs of death of 2.6 for AAA repair,
1.3 for CABG, and 3.2 for colon resection for neoplasms, compared
with elective patients.
This study represents a first attempt at estimating the im-
pact of prevention of emergent intervention. Additional benefit in
the prevention of emergent procedures is also likely found in the
well-documented benefit of screening.22–29 Still further complicating
the picture is the significant regional variation that exists in the re-
ceipt of surgery and, specifically, in the receipt of emergency versus
elective surgery, in the United States.12 For instance, compared with
the national average, patients in Nevada have a 70% higher odds of
emergency colon surgery, whereas patients in Texas have an odds
that is 53% lower.12 Interventions and policies aimed at decreasing
regional variability may help prevent emergency surgery, but system-
atic solutions are difficult to come by. Promising results have been
suggested in the realm of quality improvement, where various in-
terventions have been shown to decrease variability in practice30 and
even mortality31 in hospital-based settings. However, further research
is needed to ascertain how best to apply them to the general health
care system.
The diseases chosen for this analysis represent some of the
leading causes of death in the United States and are responsive to
early primary care intervention and diagnosis. Emergency surgery for
ruptured AAA is associated with a 50% mortality rate compared with
5% for planned intervention with specialist vascular surgeons.10 This
study confirms previous findings of higher mortality rate and mean
cost for emergent AAA repairs, suggesting significant opportunity for
screening to benefit both patients and health systems. Although the
TABLE 3. Adjusted Mean Per-patient Hospitalization Costs for Emergent and Elective Admissions Among Patients Who
Underwent AAA Repair, CABG, or Colon Resection
Surgery
Elective Mean
Adjusted Cost, $
Emergent Mean
Adjusted Cost, $
Mean Cost
Difference, $
95% Confidence
Interval for Mean
Cost Difference, $
18 yr and older
All 25,709.03 33,087.06 7,383.74 (7,304.70–7,462.79)
Colon resection 14,801.68 22,616.33 7,813.53 (7,746.33–7,880.72)
AAA repair 29,067.27 37,800.81 8,741.22 (8,597.60–8,884.84)
CABG 30,830.21 36,138.85 5,309.78 (5,234.42–5,385.14)
18- to 64-yr-olds
All 24,796.37 31,620.00 6,826.59 (6,749.11–6,904.08)
Colon resection 13,574.50 20,168.66 6,592.56 (6,529.15–6,655.97)
AAA repair 30,648.62 40,933.33 10,291.90 (10,020.52–10,563.29)
CABG 28,883.49 33,808.73 4,924.84 (4,853.49–4,996.19)
65 yr and older
All 26,290.80 34,115.39 7,831.54 (7,748.07–7,915.02)
Colon resection 15,425.19 23,855.25 8,428.64 (8,356.62–8,500.65)
AAA repair 28,601.66 36,969.44 8,371.23 (8,255.13–8,495.27)
CABG 32,485.19 38,141.71 5,658.50 (5,578.83–5,738.18)
Adjusted for propensity score quintiles, year trend, local wage index, whether or not patient died on admission, hospital’s bed size, rural/urban location, ownership, teaching
status, state, and region. All costs in 2010 US dollars.
AAA, abdominal aortic aneurysm; CABG, coronary artery bypass graft.
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2014 Wolters Kluwer Health, Inc. All rights reserved. www.annalsofsurgery.com |263
Haider et al Annals of Surgery rVolume 262, Number 2, August 2015
TABLE 4. National Estimates of Potential Cost Savings for 10% Conversion of Emergent to Elective Admission Among Patients
18 Years or Older Who Underwent AAA Repair, CABG, or Colon Resection
Surgery
Weighted
Emergent Cohort
Mean Cost
Difference, $
Accrued Cost
Savings After
10% Conversion,$
95% Confidence
Interval of Accrued
Cost Savings After
10% Conversion,$
Colon resection 238,555 7,813.53 186,395,664 (184,792,575–187,998,516)
AAA repair 102,024 8,741.22 89,181,422 (87,716,154–90,646,691)
CABG 1,008,559 5,309.78 535,522,640 (527,922,140–543,1239,141)
Total 1,349,139 7,383.74 996,169,160 (985,505,565–1,006,834,104)
All costs in 2010 US dollars.
National estimates derived by applying HCUP-NIS discharge-level weights.
Calculated by multiplying 10% of weighted cohort of emergent admissions by mean cost differences between emergent and elective admissions.
AAA, abdominal aortic aneurysm; CABG, coronary artery bypass graft.
cost of population-level screening for AAA has long been considered
too high to be economically feasible, several studies from the Europe
and Canada suggest that it is likely cost-effective.32–34 A large trial
in Denmark, which randomized 12,000 participants to routine ultra-
sound surveillance or incidental diagnosis, found that over 10 years
mortality was reduced by 73% and emergency surgery by 68% in the
screening group.35 A subsequent meta-analysis of 4 randomized trials
of population screening for AAA also showed a significant reduction
in AAA-related mortality (OR =0.47; 95% CI, 0.25–0.9) and emer-
gency surgery (OR =0.48; 95% CI, 0.28–0.83).36 The Multicentre
Aneurysm Screening Study performed a 4-year cost-effectiveness
analysis and concluded that screening was “at the margin of accept-
ability,” but that over a longer time period the cost-effectiveness ratio
would improve.37
Our study is consistent with previous findings that emergent
CABG is both more costly and more deadly.9,38 For example, it has
been demonstrated that delay in care for coronary artery disease
is an important contributor to emergency cases and mortality. In
health systems with long wait-lists for CABG, waits of greater than
a month are associated with higher mortality rate with an OR of 1.60
compared with those who underwent surgery within a month.38 Earlier
studies have also shown an increase in hospital charges associated
with emergent CABG, although they were not adjusted by CCR to
identify actual cost.9
In addition, emergency surgery is a known negative prognostic
factor for morbidity and mortality among colon cancer patients.39–43
Screening for colon cancer, even if only with fecal occult blood
testing, results in higher proportions of elective surgery with improved
outcomes.44 However, studies suggest that screening with fecal occult
blood testing and/or sigmoidoscopy or colonoscopy is quite low, with
lack of health care coverage contributing significantly to this gap.45, 46
Even those with some insurance coverage in the form of Medicaid
and/or Medicare have lower rates of screening and up to a 3-fold
higher risk of having emergency colorectal surgery.6Thus, improving
screening rates for colon cancer offers a high-impact opportunity to
prevent unnecessary emergency surgeries and reduce disparities.
As a retrospective database review, there are limitations to
this study, including reliance on data originally intended for billing
purposes. Such data have been known to systematically underreport
certain low-cost diagnostic procedures and to suffer from a lack of
nuanced clinical detail.46, 47 The trade-off for such limitations is the
availability of data on large numbers of nationally representative pa-
tients thought to yield valid results for high-revenue invasive proce-
dures, such as the types considered here.46,47 Moreover, although the
numbers for this study are impressive, they account only for direct
costs to the health care system and did not include indirect costs,
such as loss of time from work, prehospital costs, or postdischarge
medical costs. Furthermore, we were not able to determine what type
of care these particular patients may have accessed for screening and
routine care, meaning that cost savings stemming from the use of
cost-effective screening22–29or increased costs incurred via additional
testing and patients undergoing potentially unnecessary measures are
not reflected. Rather, the paper offers an isolated comparison of costs
specifically attributable to elective versus emergent surgical proce-
dures. Given the limited understanding and challenging nature of
nuanced topics such as these, future studies intended to inform and
improve extant definitions, implications, and methodologies of health
care costs ought to be explored.
Despite these limitations, even a small decrease of 10% in
emergent procedures showed a significant potential benefit and sets
the stage for further investigation. More importantly, once societal
costs, such as loss of productivity and employment, are factored in,
and differences in mortality and quality-adjusted life years assessed,
the associated benefits of elective surgery are likely to increase fur-
ther. Subsequent analysis will need to be performed to determine the
cost-effectiveness of increasing services at the primary care level,
including referral to specialists for advanced testing. In addition,
because data were based on ICD-9 codes and not verified with chart
review, there is a danger of miscoding and misclassification; however,
ICD-9 codes dictate the diagnoses used by the payers to reimburse
the hospital, so these represent real costs. Another issue may be mis-
classification of emergent versus elective admissions in the data set.
To assess any potential bias related to this, we cross-verified the 2
variables in the data set (“ATYPE” and “ELECTIVE”) that define the
type of admission and found nearly perfect agreement.
In consideration of the human and economic cost of late pre-
sentation of surgical disease,48–50 it is essential that access to primary
care and screening services is improved for patients. Ease of access
and communication between primary care providers and specialist
providers such as surgeons also need to be fostered to ensure more
seamless transitions. These efforts will improve care for all patients,
particularly minorities and low socioeconomic status patients, who
suffer disproportionately from barriers to health care and worse sur-
gical outcomes.11,51 The Accountable Care Organization model may
offer 1 potential solution by improving coordination of care and thus
increasing access to primary care services that can diagnose surgical
conditions before they become emergent.52
Within the context of the ACA, there is opportunity to facilitate
preventive care for surgical disease. McMorrow et al53 constructed
a model to predict potential utilization changes of preventive care
under the ACA. Stratifying by less than 400% of the Federal Poverty
Level versus greater than 400% Federal Poverty Level, they projected
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Annals of Surgery rVolume 262, Number 2, August 2015 Cost of Emergency Versus Elective Surgery
that 29% of differences in obtaining the recommended colon cancer
screening were attributable to coverage alone, with a conservative es-
timate of at least a 4% change in utilization under the ACA. Access to
insurance coverage still remains a powerful barrier to access to health
care. For instance, studies examining utilization of endoscopy for
colorectal cancer screening within ethnic groups find that insurance
status is the driving factor.54,55 Medicare coverage diminishes the dis-
parity across groups, although it does not eliminate it.56, 57 One key
reason for this may be that while covered, endoscopy still requires a
co-pay under Medicare that potentially discourages utilization among
those with lower income.
In regard to capacity to implement increased screening, a re-
cent study of more than 300 gastroenterologists in Arizona estimated
that they could increase their capacity for colorectal cancer screening
by 36% to 53%,58 and a program in South Carolina has successfully
trained primary care providers to perform screening colonoscopy for
an underserved population.59 Such an ability to implement increased
screening has particular importance for patients covered by Medi-
caid who may otherwise face difficulty accessing colorectal cancer
screening, for as a study from Connecticut highlights, only 46% of
gastroenterology practices there participate in Medicaid.60 Although
there are increased costs associated with screening, these are likely far
less than the excess cost associated with emergency surgery. Further
evaluation of the cost-effectiveness of strategies to prevent emergency
surgery will likely show that we can viably improve quality of care and
the economic sustainability of the US healthcare system by improv-
ing access to primary care and screening services and strengthening
coordination across the continuum of care.
ACKNOWLEDGMENTS
The funding organization of this study did not have any role in
the design and conduct of the study; collection, management, analy-
sis, and interpretation of the data; preparation, review, or approval
of the manuscript; and decision to submit the manuscript for publi-
cation. Dr Adil Haider had full access to all the data in the study and
takes responsibility for the integrity of the data and the accuracy of
the data analysis.
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Article
In this Viewpoint, the authors evaluate access to surgical care using the domains of timeliness, workforce density, infrastructure, safety, and affordability and discuss how such a framework could be applied in the United States.
Chapter
The Institute of Medicine’s publication of To Err Is Human: Building a Safer Health System in 2000 fundamentally changed the American healthcare system [1]. This book highlighted the imperfect system in which healthcare is provided and the need to improve patient safety. In the subsequent years, the delivery of high-quality care has become a top priority of contemporary medicine. Governmental bodies (i.e., Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality), regulatory agencies (i.e., The Joint Commission), professional organizations (i.e., the American College of Surgeons), private sector corporations (i.e., private insurers), and interest groups (i.e., the National Quality Forum) have all made efforts to improve the quality of healthcare in the United States. Organizations such as these are a source of clinical practice guidelines, quality measures, quality improvement (QI) initiatives, and educational campaigns that are valuable resources for patients, physicians, and hospitals. While efforts aimed at improving quality have become ubiquitous in modern healthcare, considerable room for improvement remains.KeywordsQualityImprovementComplicationsMetricsSafetyValue
Article
Background The financial burden of surgery is substantial worldwide. Postoperative complications increase costs in high-resource settings, but this is not well studied in other settings. Our objective was to review the financial impact of postoperative complications. Method Patients undergoing emergency gastrointestinal operations at a center in Kenya were reviewed between January 2017 and June 2019. In a cost analysis, we ascertained the outcome of total hospital costs, adjusted for inflation, and converted to international dollars using purchasing power parities. Costs were analyzed for their association with a postoperative complication, defined using standardized criteria. We calculated the Africa Surgical Outcomes Study surgical risk scores and clustered for discharge diagnosis in a mixed-effects generalized linear model accounting for confounding factors related to costs and complications. Results A total of 361 individuals had cost data available. The cohort had 251 men (69.5%) and 110 women (30.5%) with a median age of 41 years (interquartile range: 29–57 years). A total of 122 (33.8%) patients experienced a postoperative complication with an overall all-cause mortality rate of 10.5%. The median total cost of hospitalization was 1,949 (interquartile range: 1,516–2,788) international dollar purchasing power parities. When controlling for patient factors and diagnoses, patients who did not develop complications had costs of 2,119 (95% confidence interval 1,898–2,340) compared to costs of 3,747 (95% confidence interval 3,327–4,167) for patients who developed a postoperative complication, leading to a 77% increase of 1,628 international dollar purchasing power parities for patients with complications. Conclusion Our findings demonstrated a substantial financial burden generated by postoperative complications in patients undergoing emergency gastrointestinal operations. Reducing complications could allow cost savings, an important consideration in variable-resource settings.
Article
Background Frailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. Methods A retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. Results We identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60–0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64–0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. Conclusions In patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.
Article
Background Best-practice models delivering surgical care in the preoperative setting are unknown. In April 2018, we established a Same-Day Clinic (SDC) to increase the access and efficiency of general surgical care delivery. Methods This is a single-institution retrospective cohort study. We included patients who underwent elective laparoscopic cholecystectomy, inguinal or umbilical hernia repair. 112 patients were seen in the year prior to clinic creation; 84 were seen in the year following clinic creation. Results After clinic creation, the percentage of patients referred following an emergency department encounter decreased from 33.4 to 17.9%. Patients referred from primary care encounters increased from 28.6 to 44%. Patients who underwent pre-referral imaging decreased from 58.9% to 44%. The SDC cohort was seen 11 days sooner (40 vs. 29d). Conclusion The SDC increases access and decreases wait times to surgical treatment. It strengthens referral networks for traditionally underserved populations and reduces the burden of non-necessary preoperative imaging.
Article
Introduction Access sensitive surgical conditions should be treated electively with optimal access but result in emergency operations when access is limited. However, the rates of emergency procedures for these conditions are unknown. Methods Cross-sectional retrospective review of Medicare beneficiaries who underwent access sensitive surgical procedures (abdominal aortic aneurysm repair, colectomy for colorectal cancer, or incisional hernia repair) between 2014 and 2018. Risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, and Elixhauser comorbidities), hospital characteristics (ownership, size, geographic region, surgical volume) and type of operation were compared between planned and emergency (urgent and emergent) surgical procedures. Outcome measures were rates of emergency procedures as well as associated postoperative outcomes. Results Of the 744,818 Medicare beneficiaries undergoing access sensitive surgical procedures, 259,541 (34.9%) were done in the emergency setting. Risk-adjusted rates of emergency surgery varied widely across hospital service areas from 23.28% (lowest decile) to 54.88% (highest decile) (Odds Ratio 4.74; P < 0.001). Emergency procedures were associated with significantly higher rates of 30-d mortality (8.15% versus 3.65%, P < 0.001) and readmissions (16.28% versus 12.88%, P < 0.001) compared to elective procedures. Sensitivity analysis with younger and healthier beneficiaries demonstrated persistently high rates (23.3%) of emergency surgery with wide regional variation and worse patient outcomes. Conclusions Emergency surgery for access sensitive surgical conditions is extremely common and varied almost fivefold across United States hospital service areas. This suggests there are opportunities to improve access for these common surgical conditions.
Article
Whether patients undergo the more morbid and costly emergent rather than an elective type of surgery, may depend on many factors. Since tertiary prevention (preventing poor outcomes from emergency surgery) carries a much higher mortality than secondary prevention (preventing emergency surgery) or primary prevention (preventing the disease requiring surgery), the overall United States mortality might be reduced significantly, if emergency surgery could be avoided via high-quality primary prevention and non-surgical therapy or increasing elective surgery at the expense of emergency procedures, e.g., secondary prevention. The practice and study of acute care surgery then has the potential to broaden from a focus on the patient in the hospital emergency and operating rooms to the patient who no longer requires either, whose disease is treated or prevented in his/her/their community.
Article
Objective To evaluate the risk of financial toxicity (FT) among inpatients undergoing gynecologic cancer resections and the association of insurance status with clinical and financial outcomes. Methods Using the 2008–2019 National Inpatient Sample, we identified adult hospitalizations for hysterectomy or oophorectomy with a diagnosis of cancer. Hospitalization costs, length of stay (LOS), mortality, and complications were assessed by insurance status. Risk of FT was defined as health expenditure exceeding 40% of post-subsistence income. Multivariable regressions were used to analyze costs and factors associated with FT risk. Results Of 462,529 patients, 49.4% had government-funded insurance, 44.3% private, and 3.2% were uninsured. Compared to insured, uninsured patients were more commonly Black and Hispanic, admitted emergently, and underwent open operations. Uninsured patients experienced similar mortality but greater rates of complications, LOS, and costs. Overall, ovarian cancer resections had the highest median costs of $17,258 (interquartile range: 12,187–25,491) compared to cervical and uterine. Approximately 52.8% of uninsured and 15.4% of insured patients were at risk of FT. As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened. After risk adjustment, perioperative complications were associated with nearly 2-fold increased risk of FT among uninsured (adjusted odds ratio 1.75, 95% confidence interval 1.46–2.09, p < 0.001). Among the insured, Black and Hispanic race, public insurance, and open operative approach exhibited greater odds of FT. Conclusion Patients undergoing gynecologic cancer operations are at substantial risk of FT, particularly those uninsured. Targeted cost-mitigation strategies are warranted to minimize financial burden.
Article
Concerns have been raised over wide variation in rates of unplanned (emergency or urgent) surgery for access-sensitive surgical conditions-diagnoses requiring surgery that preferably is planned (elective) but, when access is limited, may be delayed until worsening symptoms require riskier and costlier unplanned surgery. Yet little is known about geographic and community-level factors that may increase the likelihood of unplanned surgery with adverse outcomes. We examined the relationship between community-level social vulnerability and rates of unplanned surgery for three access-sensitive conditions in 2014-18 among fee-for-service Medicare beneficiaries ages 65-99. Compared with patients from communities with the lowest social vulnerability, those from communities with the highest vulnerability were more likely, overall, to undergo unplanned surgery (36.2 percent versus 33.5 percent). They were also more likely to experience worse outcomes largely attributable to differential rates of unplanned surgery, including higher rates of mortality (5.4 percent versus 5.0 percent) and additional surgery within thirty days (19.6 percent versus 18.1 percent). Our findings suggest that policy addressing community-level social vulnerability may mitigate the observed differences in surgical procedures and outcomes for access-sensitive conditions.
Article
Full-text available
Background The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution. Methods Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location. Findings In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement. Interpretation This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan. Funding None.
Article
Full-text available
Background Implementation of the National Health Service abdominal aortic aneurysm (AAA) screening programme (NAAASP) for men aged 65 years began in England in 2009. An important element of the evidence base supporting its introduction was the economic modelling of the long-term cost-effectiveness of screening, which was based mainly on 4-year follow-up data from the Multicentre Aneurysm Screening Study (MASS) randomized trial. Concern has been expressed about whether this conclusion of cost-effectiveness still holds, given the early performance parameters, particularly the lower prevalence of AAA observed in NAAASP.Methods The existing published model was adjusted and updated to reflect the current best evidence. It was recalibrated to mirror the 10-year follow-up data from MASS; the main cost parameters were re-estimated to reflect current practice; and more robust estimates of AAA growth and rupture rates from recent meta-analyses were incorporated, as were key parameters as observed in NAAASP (attendance rates, AAA prevalence and size distributions).ResultsThe revised and updated model produced estimates of the long-term incremental cost-effectiveness of £5758 (95 per cent confidence interval £4285 to £7410) per life-year gained, or £7370 (£5467 to £9443) per quality-adjusted life-year (QALY) gained.Conclusion Although the updated parameters, particularly the increased costs and lower AAA prevalence, have increased the cost per QALY, the latest modelling provides evidence that AAA screening as now being implemented in England is still highly cost-effective.
Article
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Article
Objective: To assess the cost effectiveness of ultrasound screening for abdominal aortic aneurysms. Design: Primary analysis: four year cost effectiveness analysis based directly on results from a randomised controlled trial in which patients were individually allocated to invitation to ultrasound screening (intervention) or to a control group not offered screening. Secondary analysis: projection of the data, based on conservative assumptions, to indicate likely cost effectiveness at 10 years. Setting: Four centres in the United Kingdom. Screening delivered in primary care settings with follow up and surgery offered in the main hospitals Participants: Population based sample of 67 800 men aged 65-74 years. Main outcome measures: Mortality from and costs (screening, follow up, elective and emergency surgery) related to abdominal aortic aneurysm; cost per life year gained. Results: Over four years there were 47 fewer deaths related to abdominal aortic aneurysms in the screening group than in the control group, but the additional costs incurred were pound 2.2m. After adjustment for censoring and discounted at 6% the mean additional cost of the screening programme was pound 63.39 ($97.77, euro;100.48) (95% confidence interval pound 53.31 to pound 73.48) per patient. The hazard ratio for abdominal aortic aneurysm was 0.58 (0.42 to 0.78). Over four years the mean incremental cost effectiveness ratio for screening was pound 28 400 ( pound 15 000 to pound 146 000) per life year gained, equivalent to about pound 36 000 per quality adjusted life year. After 10 years this figure is estimated to fall to around pound 8000 per life year gained. Conclusions: Even at four years the cost effectiveness of screening for abdominal aortic aneurysms is at the margin of acceptability according to current NHS thresholds. Over a longer period the cost effectiveness will improve substantially, the predicted ratio at 10 years falling to around a quarter of the four year figure.
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Our aim was to identify predictors of colorectal cancer screening in the United States and subgroups with particularly low rates of screening.
Article
Objectives: We examined preventive care use by nonelderly adults (aged 18-64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns. Methods: We used data from the 2005-2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income. Results: There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers. Conclusions: Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.