Discussion
In our study of over 300 000 older adults with an EGS condition, over one-fifth received surgery, and 4% died during the hospitalization. Patients whose care was consistent with their predicted treatment had better outcomes—those who received discordant care were more likely to experience in-hospital mortality. Our findings demonstrated that not only that there is variation in the provision of operative management but that when patients received care which fell outside of the ‘average’ treatment paradigm, mortality was higher. This information is important for both providers and the EGS community, as these data support important ongoing work to develop improved standards for EGS practice.
Patients who received surgery tended to be younger, less frail, and have specific EGS conditions: appendicitis, gallbladder disease, hernia, ischemic bowel, and perforated viscus. Patients with diverticulitis and peptic ulcer disease were more likely to be treated non-operatively. Multiple prior studies have shown that medically complex patients or those with high levels of frailty are more likely to be treated non-operatively.9 31–33 For patients who are unlikely to survive their EGS condition no matter the treatment, non-operative management is a reasonable approach. However, non-operative management can also weaken an already frail patient and increase the increase the risk of a subsequent surgery. In studies of frail patients with appendicitis and cholecystitis using the National Readmissions Database, nearly one in five patients treated non-operatively at the index admission eventually failed and required a later surgery, which resulted in higher rates of complication and higher mortality than those who had an operation performed at the index admission.32 33
Multiple factors influence surgical decision-making in EGS conditions and can influence the surgeon’s recommendations and patients’ decisions. Instrumental qualitative work on perspectives of older patients and surgeons regarding high-stakes surgical decision-making was published by Nabozny et al, who showed that even though patients and surgeons highly value quality of life, this notion is difficult to incorporate into surgical decisions.34 Many simply view this as a simple choice between life and death, where choosing surgery is a surrogate for choosing life, even though surgery is not synonymous with survival.34 For surgeons, conversations are often framed by the structure of an informed consent, which is a poor framework for decision-making because these frameworks rely on disclosure of discrete procedural complications rather than prioritizing alignment with individual patient preferences.34 35 Surgeons struggle with framing these difficult conversations, and in some circumstances, it can be ‘easier to just operate than to explain to the family why surgery is not the right treatment.’34
Unfortunately, the current lack of data on outcomes after non-operative management limits our ability to use data to show whether there is clinical equipoise between operative and non-operative management. Clinical experience and single-center studies tend to favor operative management in those who can tolerate the operation. For those who are referred to surgery but cannot tolerate an operation, outcomes are poor. A single-center retrospective study examined outcomes after non-operative EGS management and showed very high 1-year mortality rates: 11% at 30 days and 23% at 1 year. When surgical consultants deemed the patient too high risk for an operative procedure, the 1-year mortality was 53%.36 However, these single-center studies may have selection bias, as these are patients who have been selected for a surgical consultation. Population-based long-term studies may show more potential for equipoise in certain clinical scenarios. A study by Kaufman et al used Medicare data to examine patient populations using a matched instrumental variable analysis and found that mortality over 180 days varied by condition. Although operative management in hepatobiliary conditions was associated with a lower risk of mortality at 30, 90, and 180 days, in upper gastrointestinal and colorectal conditions, the opposite was true.9
This study had several key limitations, mostly related to the use of administrative data. A key limitation of the study is that the NIS does not have any clinical information about disease severity, functional status, other terminal diseases, or patient preferences, which could have influenced treatment decisions and outcomes; likewise, no information was extracted about non-operative management strategies such as use of antibiotics or drains. In addition, these data are older, from 2016 to 2017; these data allowed use of ICD code methodologies that were developed previously and avoided changes in decision-making that occurred during the COVID-19 pandemic. To limit the effect of the lack of functional status, our propensity score did include not only Elixhauser diagnoses, but 38 diagnoses which are included in a deficit accumulation frailty score. The deficit accumulation method is a reproducible method which can quantify frailty, which can serve well as a proxy for development of functional deficits and accelerated aging.27–29 37 Another potential limitation of our study is the inability to account for variation in provider and hospital characteristics, such as medical and surgical expertise and biases. Our study was also only able to examine in-hospital mortality as the outcome of interest, which limits our understanding of the overall impact of treatment decisions on long-term patient quality of life. In some circumstances, such as the patient who is unlikely to survive an operation, non-operative management despite a high probability for surgery may be the preferred treatment strategy despite high mortality. Because our study goal was to outline existing variation in surgical practice for the field of EGS, examining nuances between varying disease types was also outside the scope of this study. It is likely that the variation between practices and the effects of that variation differ greatly between EGS disease types.
In summary, the aim of this study was to characterize variation in use of operative management for EGS conditions in the USA; our secondary aim was to determine if this variation had subsequent clinical consequences. Our findings highlight that there is variation in provision of operative management in EGS conditions, and that patients had a higher risk of mortality if they received care which was not concordant with the treatment which was predicted. By demonstrating the consequences of variation in care, our study underscores the need for further studies that examine whether standardized treatment protocols or decision aids can reduce variation and improve care. Our study suggests that there is an opportunity to improve operative decision-making in EGS care through reduction of variation.