Operative Decision Discordance in Geriatric Emergency General Surgery

Nearly 1 million older adults are hospitalized annually for emergency general surgery (EGS) conditions in the United States. Recent literature has demonstrated the impact of discordant care in EGS, defined as a mismatch between treatment choice and patients’ clinical risk profile. In the present work, we characterize the association between preoperative decision variation and outcomes in elderly EGS patients. Methods All geriatric (≥65 years) hospitalizations with EGS conditions (appendicitis, diverticulitis, cholecystitis, hernia, bowel obstruction, perforated peptic ulcer, intestinal ischemia, perforated bowel) were tabulated from the 2022 National Inpatient Sample (NIS). A propensity score (PS) was developed to estimate the likelihood of undergoing operative management. Low and high probability for surgery was defined using a cut-off of PS = 0.5. Model-concordant cases were defined as those whose treatment matched their predicted likelihood, while model-discordant cases did not. Multivariable regression models were developed to determine the association of care variation on outcomes. Results Of an estimated 900 730 patients with EGS conditions, 154 300 (17.1%) were classified as model-discordant. Following risk adjustment, model-discordance was associated with greater odds of mortality (AOR: 1.33, 95% CI: 1.25-1.42), as well as gastrointestinal (AOR: 2.07, 95% CI: 1.95-2.19), infectious (AOR: 1.41, 95% CI: 1.36-1.46), and respiratory (AOR: 1.26, 95% CI: 1.20-1.32) complications. Furthermore, model-discordance was associated with increased hospitalization costs (β: +$9 760, 95% CI: +$9 255-10 265) and length of stay duration (β: +2.72 days, 95% CI: +2.59-2.84). Conclusion Patients classified as model-discordant exhibited elevated rates of in-hospital mortality and postoperative complications. Given this variation, our study warrants investigation into guideline adherence and outcomes in this vulnerable population.