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The no-operation quality assessment ‘blind spot’

Key clinical point: Quality assessment of surgical outcomes does not account for cases that are managed medically without an operation; this study evaluated nonoperative management for four common diagnoses of abdominal pain.

Major finding: The overall rate of nonoperative management for diverticulitis, small bowel obstruction, cholecystitis, and appendicitis was 32.8% with rates increasing steadily over the 13-year study period.

Data source: An analysis of a sampling of 1.6 million admissions from the Nationwide (National) Inpatient Sample from 1998 to 2011, with concentration on data from 2010 and 2011.

Disclosures: The study authors reported having no relevant financial disclosures.


 

AT THE ACADEMIC SURGICAL CONGRESS

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JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. Michael Wandling Richard Mark Kirkner

Dr. Michael Wandling

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

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