title: Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals.
abstract: BACKGROUND
  Surgical quality improvement has focused on elective general surgery (ELGS) outcomes despite the substantial risk associated with emergency general surgery (EMGS) procedures. Furthermore, any differences in the quality of care provided to EMGS versus ELGS patients are not well described. We compared risk factors and risk-adjusted outcomes associated with EMGS and ELGS procedures to assess whether hospitals have comparable outcomes across these procedures.
  
  
  METHODS
  Using American College of Surgeons National Surgical Quality Improvement Program data (2005 to 2008), regression models were constructed for 30-day overall morbidity, serious morbidity, and mortality among all patients, EMGS patients, and ELGS patients. Observed-to-expected (O/E) ratios were calculated from models based on EMGS or ELGS patients. Association of hospital performance after EMGS versus ELGS procedures was assessed by evaluating correlations of O/E ratios; agreement in outlier status (hospitals where O/E confidence intervals [CI] do not overlap 1.0) was evaluated with weighted kappa.
  
  
  RESULTS
  Of 473,619 procedures, 67,445 (14.2%) patients underwent an EMGS procedure. EMGS patients were more likely to experience any morbidity (odds ratio [OR] 1.20; 95% CI 1.16 to 1.23), serious morbidity (OR 1.26; 95% CI 1.21 to 1.30), and mortality (OR 1.39; 95% CI 1.30 to 1.48). Correlation between O/E ratios for EMGS and ELGS were moderate to low (overall morbidity = 0.48, p < 0.0001; serious morbidity = 0.41, p < 0.0001, mortality = 0.18, p = 0.01). Outlier status was not consistent across EMGS and ELGS, with only slight agreement (overall morbidity = 0.18, p < 0.0001; serious morbidity = 0.16, p = 0.001, mortality = 0.19, p = 0.01).
  
  
  CONCLUSIONS
  EMGS patients are at substantially greater risk than ELGS patients for adverse events. Hospitals do not appear to have highly consistent performance across EMGS and ELGS outcomes. Processes of care that afford improved outcomes to EMGS patients need to be identified and disseminated.
authors.affiliation: Department of Surgery, University of Cincinnati College of Medicine, OH 45267-0558, USA.
authors.forename: Angela M
authors.initials: AM
authors.lastname: Ingraham
authors.forename: Mark E
authors.initials: ME
authors.lastname: Cohen
authors.forename: Mehul V
authors.initials: MV
authors.lastname: Raval
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D017558:Elective Surgical Procedures / Q000401:mortality / Q000592:standards; D004638:Emergency Treatment / Q000401:mortality / Q000592:standards; D017052:Hospital Mortality; D006761:Hospitals / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D058996:Quality Improvement; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000592:standards*; D016896:Treatment Outcome; D014481:United States