Transferred emergency general-surgery patients arrive sicker

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By Will Boggs MD

NEW YORK (Reuters Health) - Transferred emergency general surgery (EGS) patients have slightly higher mortality and morbidity rates, compared with directly admitted patients, according to a new study.

"The most interesting result was that even though we still found transfer status to be a significant predictor of mortality and morbidity, the effect was small," Dr. Manuel Castillo-Angeles from Brigham and Women's Hospital, in Boston, told Reuters Health by email.

EGS transfers have increased by 150% in the last decade, and previous research has shown that transfer EGS patients have worse outcomes than directly admitted EGS patients.

Dr. Castillo-Angeles's team used data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) from 2005 to 2014 to assess the impact of transfer status on patients who underwent an EGS procedure.

Interhospital transfers accounted for 6.85% of the more than 222,000 patients included in the study.

Transferred patients arrived in a worse state than did patients admitted directly from home: They were 1.5 times more likely to arrive with sepsis and four times more likely to experience septic shock prior to the operation, and they had significantly worse preoperative laboratory values.

In unadjusted analyses, overall mortality was significantly higher for transferred patients (10.8%) than for patients admitted directly from home (3.1%).

Transferred patients were also significantly more likely to develop any complication (37.8% vs. 16.8%) and to undergo reoperation (9.1% vs. 3.4%), and had longer postoperative hospital stays (five days vs. two days).

In propensity score-matched analysis, however, transferred patients had only 1% greater odds of overall mortality, 7% greater odds of developing any complication and 6% greater odds of experiencing a major complication, the researchers report in the Journal of the American College of Surgeons, online January 31. All risk increases were statistically significant.

In subgroup analyses, transfer status was not associated with worse outcomes for patients undergoing low-risk operations. For high-risk procedures, though, transfer patients did have a significantly higher risk of any complication or a major complication, compared with directly admitted patients.

"Transferred EGS patients were sicker upon arrival to the operating hospital," Dr. Castillo-Angeles said. "However, after strict risk adjustment, our study showed that these patients could be safely transferred and this would not necessarily translate into worse outcomes, particularly for low-risk EGS procedures."

"We have seen how regionalization of care has worked in the trauma and oncologic surgery population with favorable outcomes," he said. "The results of this study could be a first step towards centralizing resources that could potentially reduce costs and improve outcomes within the EGS population."

Dr. Castillo-Angeles added, "The other important point is that transfer status is not currently taken into account by most risk calculators. At least within the EGS population, it should be taken into account for clinical performance benchmarking."

"Further studies are needed to define the role of regionalization of EGS care and to develop the best processes and guidelines to determine which EGS patients should be transferred," the researchers note.

SOURCE: https://bit.ly/2GtuYgW

J Am Coll Surg 2019.

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