title: Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team.
abstract: OBJECTIVE
  To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions.
  
  
  BACKGROUND
  Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies.
  
  
  METHODS
  Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions.
  
  
  RESULTS
  Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32).
  
  
  CONCLUSIONS
  This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.
authors.affiliation: *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Aquina
authors.forename: Adan Z
authors.initials: AZ
authors.lastname: Becerra
authors.forename: Christian P
authors.initials: CP
authors.lastname: Probst
authors.forename: Zhaomin
authors.initials: Z
authors.lastname: Xu
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Hensley
authors.forename: James C
authors.initials: JC
authors.lastname: Iannuzzi
authors.forename: Katia
authors.initials: K
authors.lastname: Noyes
authors.forename: John R T
authors.initials: JR
authors.lastname: Monson
authors.forename: Fergal J
authors.initials: FJ
authors.lastname: Fleming
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007297:Inpatients; D007415:Intestinal Obstruction / Q000191:economics / Q000601:surgery* / Q000628:therapy; D007421:Intestine, Small; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012985:Software Design; D000267:Tissue Adhesions; D016896:Treatment Outcome