Abstract
Background
Small bowel obstructions (SBOs) account for a significant burden on the health care system. Should the ongoing trend of regionalizing medicine extend to these patients? We investigated if there is a benefit to admitting SBOs to larger teaching hospitals and to surgical services.
Methods
We performed a retrospective chart review of 505 patients admitted to a Sentara Facility between 2012 and 2019 with a diagnosis of SBO. Patients between the ages of 18 and 89 were included. Patients were excluded if they required emergent operation. Outcomes were evaluated based on patient’s admission either to a teaching or community hospital as well as the admitting service’s specialty.
Results
Of 505 patients admitted with a SBO, 351 (69.5%) were admitted to a teaching hospital. 392 (77.6%) patients were admitted to a surgical service. The average length of stay (LOS) (4 vs 7 days, P < .0001) and cost ($18,069.79 vs $26,458.20, P < .0001) were lower at teaching hospitals. The same trends in LOS (4 vs 7 days, P < .0001) and cost ($18,265.10 vs $29 944.82, P < .0001) were seen with surgical services. The 30-day readmission rate was higher in teaching hospitals (18.2% vs 11%, P = .0429), and no difference was seen in operative rate or mortality.
Discussion
These data would suggest that there is a benefit to admitting SBO patients to larger teaching hospitals and to surgical services with regard to LOS and cost, suggesting that these patients might benefit from treatment at centers with emergency general surgery (EGS) Services.
Key Takeaways
• Patients with small bowel obstructions admitted to larger teaching hospitals and to surgical services had a decreased length of stay and hospital cost. • However, the 30-day readmission rate was higher in patients admitted to a teaching hospital. • The findings support efforts to regionalize emergency general surgery services because of the improvements in cost and length of stay associated with admission to teaching hospitals and to surgical services.
Introduction
Small bowel obstructions (SBOs) are a common surgical condition and are associated with a substantial impact on emergency general surgery (EGS) services and patient quality of life. The condition accounts for 300 000 admissions, leading to 850 000 days of inpatient care and $1.3 billion annually.1,2 27–42% of SBO require operative intervention, and SBOs contribute to 2000 deaths annually in the US.2,3 For patients not requiring emergent operations, the current standard is nasogastric decompression following by a water-soluble contrast small bowel follow through (SBFT). Since the integration of the SBFT, patients with SBOs have lower rates of operative exploration, length of stay (LOS), and hospital cost.1,4,5 While the SBFT has been proven to be both diagnostic and therapeutic,6,7 it can delay operative intervention by several days. This delay may be further exacerbated by the limitations of the admitting hospital. While performing a SBFT early can decrease hospital LOS, cost, and morbidity, smaller hospitals unfortunately may not have the ability to perform a SBFT overnight or on weekends.
Further, there has been an increasing push to regionalize EGS by creating a coordinated, geographical system to optimize patient care. It is theorized that the implementation of a regionalized, tiered EGS system would yield significant survival benefits since regionalization has been a longstanding model for trauma care. It is estimated that 1 in 10 risk-adjusted deaths could be prevented by a structured EGS system. 8 This would help to combat a national crisis in emergency surgical care involving workforce deficiencies including the shortage of general surgeons and insufficient operating room access and staffing.8,9 While there are not defined “EGS centers,” improved surgical outcomes of a larger teaching hospital for common EGS conditions may mimic the goals of regionalization. This study aims to determine if there is an advantage to admitting patients with a SBO to larger teaching hospitals and to a surgical service in regard to LOS, cost of stay, operative intervention, 30-day readmission, and 30-day mortality.
Methods
Institutional Review Board approval for this retrospective review was obtained, and the requirement for informed consent was waived. A retrospective chart review was performed of 505 patients who were admitted with a diagnosis of SBO to a Sentara Facility between January 1, 2012, and July 31, 2019. Patients aged 18 to 89 were included. The facilities included Sentara Albemarle Hospital, Sentara CarePlex Hospital, Sentara Leigh Hospital, Sentara Norfolk General, Sentara Northern VA Medical Center, Sentara Obici Hospital, Sentara Princess Anne Hospital, Sentara Virginia Beach General, and Sentara Williamsburg Regional Medical Center. Patients were excluded if they underwent emergent operation.
Patients were divided into categories based on the hospital type (teaching vs community) and the specialty of the admitting service (general surgery vs internal medicine). A teaching hospital was defined as a hospital with residents on the service. The groups were compared with regards to age, gender, BMI, LOS, cost of stay, operative intervention, 30-day readmission, and 30-day mortality.
Descriptive statistics, including median (interquartile range), min, max, standard error, or frequency, has been utilized to summarize the data. T-test was utilized to compare the mean of cases and control groups. A chi-squared test was used for comparisons between categorical variables. All hypothesis testing was carried out at the 95% significant level with a P value of <.05 accepted as statistically significant.
Results
Population Characteristics.
Comparisons Within Hospital Type.
Comparisons Within Admitting Specialty.
Discussion
Overall, patients with SBO admitted to larger teaching hospitals and to surgical services had a decreased LOS and hospital cost. However, the 30-day readmission rate was higher in patients admitted to a teaching hospital. This study would suggest that there is a potential benefit to patients with a SBO being admitted to larger teaching hospitals and to surgical specialties with regard to LOS and total hospital cost.
This study complements others in respect to the advantage of admitting patients with SBO to a surgical service. These studies draw a similar conclusion in favor of surgical services for a shorter LOS and less hospital charges.10-13 In addition to the advantages in LOS and cost, Aquina et al found that admission to a surgical specialty correlated with decreased 30-day readmission rates, and Oyasiji et al identified lower mortality rates with surgical admission in both operative and non-operative groups. In this study, we did not find significant differences in 30-day readmission and mortality among admitting specialties. Unlike the present study, many of the studies investigating the impact of the admitting service drew data from a single institution.10-12 While Aquina et al incorporated data from multiple institutions, their study did not conduct an analysis for the type of hospital.
As this study investigates the impact of treatment with a surgical service and a larger teaching hospital, the findings support efforts to regionalize EGS services because of the improvements in cost and LOS. The surgical services at teaching hospitals approximate the benefits of EGS centers with respect to resources and volume. Furthermore, establishment of such centers would help to lessen the inequities in access to EGS services nationwide.8,14 As with the standardized approach to trauma care, EGS services may stand to benefit from a similar approach. A well-defined, tiered system could improve triage and expedite transfer to institutions with the capabilities for more advanced care.8,14
As a retrospective chart review, there are limitations to the study. Patient comorbidities were not collected and could not be analyzed for potential discrepancies between groups. This is especially important since comorbidities such as CAD and AKI are significant predictors of mortality in SBO patients. 12 Additionally, the cost and additional hospital days of those readmissions were not evaluated. Therefore, we cannot accurately conclude that there is a true benefit to having patients admitted to a teaching hospital since the findings indicated higher readmission rates with the teaching hospitals. While we cannot definitively conclude the benefit of admission to a teaching hospital, there does still appear to be a benefit to admitting patients to a surgical service.
Future work should expand upon this study to assess the impact of patient comorbidities on the data. In future studies, we would also like to incorporate readmission data to obtain a more accurate gauge on the impact of admission to a teaching hospital. Overall, this study supports admitting SBO patients to larger teaching hospitals and to surgical services.
Conclusion
Patients with SBO may benefit from admission to larger teaching hospitals and to surgical services to decrease LOS and total hospital cost, which suggests that these patients might best be treated at centers with emergency general surgery services.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.