Data Suggest Viability of Acute Care Surgery

NAPLES, FLA. – Switching to an acute care surgery service model increased productivity and job satisfaction among trauma surgeons without a negative impact on general surgeons at a level I university-based trauma center.

Integrating the trauma, critical care, and emergent and elective general surgery into a single acute care surgery (ACS) division at the University of Missouri Hospital, Columbia, significantly increased total annual work relative-value units (wRVUs) by 94% when compared with the prior period under a traditional trauma-only model. This included a dramatic and statistically significant 122% increase in monthly operative wRVUs and a 78% increase in evaluation and management (E&M) services, Dr. Christopher Cooper said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Contrary to fears of a negative impact on general surgery, total annual wRVUs rose 8% in the general surgery service over the same period. This included a significant 14% increase in monthly operative wRVUs and a 15% decrease in E&M services.

One full-time employee (FTE) was needed to establish the ACS division in November 2008, while FTEs remained constant at nine in the general surgery division. Bariatrics was excluded from the analysis, which included productivity data from November 2007 to October 2009.

As expected with the transition of emergency general surgery coverage to ACS, the emergent case volume rose 129% for ACS and fell 51% for general surgery. Elective case volume increased 44% for ACS, resulting in a 66% increase in total annual case volume. Elective case volume increased 3% for general surgery, but the reduction in emergent cases resulted in a 9% decline in overall general surgery operative volume, said Dr. Cooper, a second-year general surgery resident at the university.

On the basis of a 10-point subjective scale, job satisfaction after the transition to an ACS model increased a significant 80% for the four trauma/ACS surgeons surveyed and increased about 5% for the six general surgeons surveyed. Case mix diversity increased dramatically after the transition, according to ACS surgeons, and decreased slightly among general surgeons, although this allowed them to have a more focused clinical practice, Dr. Cooper said.

ACS surgeons reported that the transition to an ACS model had a positive financial impact on their practice and increased their case volume. General surgeons said the transition had no financial impact on their practice and noted no change in their case volume, despite the overall 9% decline in operative volume observed in the study.

Acknowledging that the analysis did not account for increased departmental costs in creating an ACS division, Dr. Cooper called for further longitudinal analysis of the long-term sustainability of the findings.

At the start of his talk, Dr. Cooper observed that the increase in nonoperative management of trauma cases has contributed to low provider job satisfaction, dwindling interest among residents, and unfilled trauma surgery fellowships.

"The development of ACS as a general surgery subspecialty may significantly improve resident interest in trauma surgery and careers in acute care surgery," he concluded to a strong round of applause.

Invited discussant Dr. Don Fishman, medical director of trauma services at Overland Park (Kansas) Regional Medical Center, agreed and said the paper was reminiscent of the famous Life cereal commercial, in which two boys successfully coax the freckle-faced Mikey to try a bowl of cereal.

"Trauma tried to get the hospital to try this model, and low and behold, everyone was satisfied with the outcome," he said. "I believe this will continue to happen across America."

Dr. Fishman asked whether the increases observed in the study have persisted over the past year, because otherwise, as surgical reimbursement falls, general surgeons might want to take back some of their cases, particularly since many emergent cases are performed during the day rather than at night.

Dr. Cooper responded that E&M productivity has remained flat, but operating volume and total wRVUs have continued to increase at the same rate for the ACS division.

Dr. Cooper and Dr. Fishman reported no conflicts of interest.