Hospital Variation in Geriatric Surgical Safety for Emergency Operation

Background The American College of Surgeons maintains that surgical care in the United States (US) has not reached optimal safety and quality. This may partially be driven by higher-risk, emergency operations in geriatric patients. We therefore sought to answer two questions: First, to what degree does standardized postoperative mortality vary in hospitals performing non-elective operations in geriatric patients? Second, can the differences in hospital-based mortality be explained by patient-, operative-, and hospital-level characteristics among outlier-institutions? Study Design Patients ≥65 years who underwent one of eight common emergency general surgery (EGS) operations were identified using the California State Inpatient Database (2010-2011). Expected mortality was obtained from hierarchical, Bayesian mixed-effects logistic regression models. A risk-adjusted hospital-level standardized mortality ratio (SMR) was calculated from observed-to-expected in-hospital deaths. "Outlier" hospitals had an SMR 80% confidence interval that did not cross the average SMR of 1.0. High-mortality (SMR >1.0) and low-mortality (SMR Results 24,207 patients were included from 107 hospitals. SMR varied widely, from 2.3 (highest) to 0.3 (lowest). 11 hospitals (10.3%) were poor-performing high-SMR outliers, while 10 hospitals (9.3%) were exceptional-performing low-SMR outliers. SMR was 3-times worse in the high-SMR compared to the low-SMR group (1.7 vs 0.6; p Conclusion Significant hospital variation exists in standardized mortality after common general surgery operations done emergently in older patients. More than 10% of institutions have substantial excess mortality. These findings confirm that the safety of emergency operations in geriatric patients can be significantly improved by decreasing the wide-variability in mortality-outcomes.