The burden of emergency general surgery (EGS) disease is significant and increasing, with some estimates suggesting that EGS diagnoses account for 50% of surgical mortality.1 2 There are many in the surgical community who believe that EGS is simply general surgery that is ‘done in the middle of the night’. We have failed to appropriately describe the significant physiological, immunological, and metabolic aspects of EGS and the burden it places on the patient and the healthcare system. Furthermore, we have not sufficiently addressed how socio-economic factors, such as having adequate healthcare coverage, affect outcomes associated with EGS.
An additive stressor to the burgeoning EGS issue is the rapid growth of the elderly population across the world. EGS outcomes are significantly worse than the same process treated on an elective basis. Similarly, outcomes for elderly patients who present with complications of frailty and multiple medical comorbidities are worse than their healthier counterparts.3 It is completely reasonable to expect that elderly frail patients with EGS disease processes are going to do poorly. But are there other factors that can affect these outcomes?
In Pakistan, at the Aga Khan University Medical College, investigators have found in a secondary analysis of a large sample size that older patients who lack insurance have worse outcomes in EGS.4 There were several very important take home messages from this manuscript. They found that the self-paid cohort had 17% higher odds of developing a complication than those with insurance and were operated on less frequently than those with insurance. It is hypothesized that the financial strain that prevents them from purchasing insurance also affects their ability to afford surgical interventions. Also, as we often see in the USA, self-pay patients present to the emergency room (ER) later with more advanced disease process, ultimately resulting in greater morbidity and mortality. Indeed, these authors found that there was significant reduction in survival time for those patients admitted through the ER versus those (insured patients) who were admitted from the clinic. Additionally, those patients who were older than 80 years had a 16% higher odds of developing a complication. Conversely, those older patients who underwent an operation were 36% less likely to experience mortality than those who did not. This highlights the critical need for early identification and treatment of EGS disease processes. Despite being elderly, there is significant improvement when undergoing the appropriate operations.
One shortcoming of this study was the inability to provide information on mortality after 30 days. The 30-day mortality is a standard measuring unit for many trials. When it comes to the issue of how insurance, or the act of receiving longstanding preventative care, affects mortality for acute issues such as EGS, a longer follow-up measure of mortality would likely be a better measure to assess difference in access to care.
This study highlights the protective effect of healthcare coverage on EGS conditions in the elderly. An EGS diagnosis can affect anyone, but this study shows that there are decreased complications for those who are able to obtain continuous healthcare oversight and monitoring. This allows for the earlier identification of problems that can be treated on an elective basis instead of as an emergency. If a patient has no insurance and cannot afford to pay the daily hospital bill (as provided in Pakistan), it should be no surprise that patients will try and ‘wait out’ any ailment for hopes that it will resolve without therapy. For those illnesses that do not resolve, it becomes an emergency situation with significantly increased untoward outcomes.
This issue is not isolated to Pakistan. Nor is it relegated to safety net hospitals in the USA. Self-pay is the third largest payer behind Medicare and Medicaid and has continued to grow from 2012 to 2021.5 The data presented in this manuscript highlight the issue that is already a major issue in the global healthcare system and is likely only going to get worse. The best way to improve the care for these patients is to be able to provide increased access to primary care to manage the patient’s comorbidities alongside the developing surgical issue.