Patients undergoing emergency abdominal surgery managed by high volume surgeons have better survival outcomes – RCSI study

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Kenneth Mealy

Emergency abdominal surgery patients under the care of high volume surgeons are more likely to survive, according to a study led by RCSI.

The study, the first to demonstrate an association between surgeon volume and mortality outcomes in emergency abdominal surgery, shows that low volume surgical teams had consistently higher mortality for emergency abdominal surgery than high volume surgical teams.

The study was undertaken by the Healthcare Outcomes Research Centre at RCSI and the National Clinical Programme in Surgery and is published by BMJ Open. It analysed 10,344 emergency abdominal surgeries carried out between 2014 and 2018 across 24 public hospitals. From the total number of surgeries, 798 patients died in hospital, giving an overall in-hospital mortality rate of 77 per 1,000 patients. The study found that low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1,000 patients) compared with high volume teams (54.7 deaths/1,000 patients), a difference that persisted among low volume surgeons practising in high volume hospitals.

High volume surgical teams are categorised as those who performed more than 12 procedures a year during the five years of the study and low volume teams performed less than 6 procedures each year. High volume hospitals performed more than 90 procedures each year and low volume hospitals performed less than 50 procedures.

Emergency abdominal surgery is considered high-risk, in Ireland and internationally, and it is associated with significant mortality and morbidity. Outcomes are poorest for older and frail patients as well as patients from ethnic minorities and lower socioeconomic groups.

The relationship between hospital or surgeon volume and mortality of patients undergoing emergency abdominal surgery is poorly understood, according to lead author of the study, Deirdre Nally. “Our objective was to determine mortality following these surgeries at the national level and to investigate the relationship between volume and mortality. Specifically, this study examines the relationship between hospital volume and surgeon volume and in-hospital mortality. Improved understanding of this relationship can inform policy decisions regarding the structure of emergency abdominal surgery at regional and national levels”.

RCSI President and study co-author Mr Kenneth Mealy said: “This is an important study with implications which need to be considered by the Hospital Groups, HSE, National Clinical Programme in Surgery and at political level.

“For many years now, we have argued that reconfiguring surgical services in Ireland with surgeries carried out in the most appropriate setting would improve patient outcomes. Following this study, the question which must now be considered is whether or not low volume surgeons or low volume hospitals should continue to provide on-call acute surgical services and patients will fairly ask to which hospital they should present with an acute abdominal concern.

“Our objective in undertaking this study and disseminating the findings is to help inform a critical and ongoing conversation about the future structure of emergency surgical services in Ireland. I urge all of the parties involved to address these issues as a matter of urgency so that patients can be provided with the answers they will seek and so that outcomes can improve,” added Mr Mealy.

Mr Mealy said that: “Data on healthcare outcomes should be at the centre of decision-making in health policy. Through our involvement in the National Clinical Programme in Surgery and the Healthcare Outcomes Research Centre (HORC) at RCSI, we will continue to develop and disseminate evidence-based research on healthcare outcomes to inform policy and improve patient outcomes.”