Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database

A. Hutchings; S. O’Neill; D. Lugo-Palacios; S. Moler Zapata; R. Silverwood; D. Cromwell; L. Keele; G. Bellingan; S. R. Moonesinghe; N. Smart; R. Hinchliffe; R. Grieve

doi:10.1111/anae.15730

Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database

A. Hutchings
, S. O’Neill
, D. Lugo-Palacios
, S. Moler Zapata
, R. Silverwood
, D. Cromwell
, L. Keele
, G. Bellingan
, S. R. Moonesinghe
, N. Smart
, R. Hinchliffe
, R. Grieve^*

^*Corresponding author for this work

Research output: Contribution to journal › Article (Academic Journal) › peer-review

23 Citations (Scopus)

190 Downloads (Pure)

Abstract

The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: −0.73 days (−2.10–0.64) for appendicitis; 0.60 (−0.10–1.30) for gallstone disease; −2.66 (−15.7–10.4) for diverticular disease; −0.07 (−2.40–2.25) for hernia; and 3.32 (−3.13–9.76) for intestinal obstruction. For patients with ‘severe frailty’, mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: −21.0 (−27.4 to −14.6) for appendicitis; −5.72 (−11.3 to −0.2) for gallstone disease, −38.9 (−63.3 to −14.6) for diverticular disease; −19.5 (−26.6 to −12.3) for hernia; and − 34.5 (−46.7 to −22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: −0.18 (−1.56–1.20) for appendicitis; 0.93 (0.48–1.39) for gallstone disease; 5.35 (−2.56–13.28) for diverticular disease; 2.26 (0.37–4.15) for hernia; and 18.2 (14.8–22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.

Original language	English
Pages (from-to)	865-881
Number of pages	17
Journal	Anaesthesia
Volume	77
Issue number	8
DOIs	https://doi.org/10.1111/anae.15730
Publication status	Published - 19 May 2022

Bibliographical note

Funding Information:
The ESORT study is funded by the National Institute for Health Research Health Services and Delivery Research. This report is also independent research supported by the National Institute for Health Research ARC North Thames. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The authors acknowledge the ESORT study's independent advisory group for the helpful discussions: Mr I. Anderson (Chair), Professor Sir N. Black, Mr P. Charlton, Dr N. Gutacker, Professor C. Hewitt, Ms S. Moug and Mr R. Vohra. They also thank those who participated in the patient and public involvement panel for the ESORT study in July 2020 for their helpful thoughts, and they appreciate the work of B. Silver who managed the ESORT study, and C. Snowden who led the patient and public involvement workshops. They thank their colleagues who made time, during the early months of the COVID-19 pandemic, to attend the clinical panels – M. Bedford, N. Blencowe, A. de Beaux, M. Evans, D. Hariharan, D. Harji, M. Lee, S. Lockwood, F. McDermott, S. Moug, D. Vimalachandran and R. Vohra. Further details are available in the Clinical Panel report: https://www.lshtm.ac.uk/media/39151. No other external funding or competing interests declared.

Funding Information:
This work was supported by the National Natural Science Foundation of China (31572599), Key Special Project for Introduced Talents Team of Southern Marine Science and Engineering Guangdong Laboratory, Guangzhou (GML2019ZD0402) and Shanghai Universities First‐class Disciplines Project of Fisheries.

Publisher Copyright:
© 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

Keywords

abdominal wall hernia
acute appendicitis
diverticular disease
emergency surgery
gallstone disease
intestinal obstruction
surgery

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Hutchings, A., O’Neill, S., Lugo-Palacios, D., Moler Zapata, S., Silverwood, R., Cromwell, D., Keele, L., Bellingan, G., Moonesinghe, S. R., Smart, N., Hinchliffe, R., & Grieve, R. (2022). Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database. Anaesthesia, 77(8), 865-881. https://doi.org/10.1111/anae.15730

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title = "Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database",

abstract = "The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95\%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: −0.73 days (−2.10–0.64) for appendicitis; 0.60 (−0.10–1.30) for gallstone disease; −2.66 (−15.7–10.4) for diverticular disease; −0.07 (−2.40–2.25) for hernia; and 3.32 (−3.13–9.76) for intestinal obstruction. For patients with {\textquoteleft}severe frailty{\textquoteright}, mean differences (95\%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: −21.0 (−27.4 to −14.6) for appendicitis; −5.72 (−11.3 to −0.2) for gallstone disease, −38.9 (−63.3 to −14.6) for diverticular disease; −19.5 (−26.6 to −12.3) for hernia; and − 34.5 (−46.7 to −22.4) for intestinal obstruction. For patients without frailty, the mean differences (95\%CI) in days alive and out of hospital were: −0.18 (−1.56–1.20) for appendicitis; 0.93 (0.48–1.39) for gallstone disease; 5.35 (−2.56–13.28) for diverticular disease; 2.26 (0.37–4.15) for hernia; and 18.2 (14.8–22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.",

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author = "A. Hutchings and S. O{\textquoteright}Neill and D. Lugo-Palacios and \{Moler Zapata\}, S. and R. Silverwood and D. Cromwell and L. Keele and G. Bellingan and Moonesinghe, \{S. R.\} and N. Smart and R. Hinchliffe and R. Grieve",

note = "Funding Information: The ESORT study is funded by the National Institute for Health Research Health Services and Delivery Research. This report is also independent research supported by the National Institute for Health Research ARC North Thames. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The authors acknowledge the ESORT study's independent advisory group for the helpful discussions: Mr I. Anderson (Chair), Professor Sir N. Black, Mr P. Charlton, Dr N. Gutacker, Professor C. Hewitt, Ms S. Moug and Mr R. Vohra. They also thank those who participated in the patient and public involvement panel for the ESORT study in July 2020 for their helpful thoughts, and they appreciate the work of B. Silver who managed the ESORT study, and C. Snowden who led the patient and public involvement workshops. They thank their colleagues who made time, during the early months of the COVID-19 pandemic, to attend the clinical panels – M. Bedford, N. Blencowe, A. de Beaux, M. Evans, D. Hariharan, D. Harji, M. Lee, S. Lockwood, F. McDermott, S. Moug, D. Vimalachandran and R. Vohra. Further details are available in the Clinical Panel report: https://www.lshtm.ac.uk/media/39151. No other external funding or competing interests declared. Funding Information: This work was supported by the National Natural Science Foundation of China (31572599), Key Special Project for Introduced Talents Team of Southern Marine Science and Engineering Guangdong Laboratory, Guangzhou (GML2019ZD0402) and Shanghai Universities First‐class Disciplines Project of Fisheries. Publisher Copyright: {\textcopyright} 2022 The Authors. Anaesthesia published by John Wiley \& Sons Ltd on behalf of Association of Anaesthetists.",

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doi = "10.1111/anae.15730",

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Hutchings, A, O’Neill, S, Lugo-Palacios, D, Moler Zapata, S, Silverwood, R, Cromwell, D, Keele, L, Bellingan, G, Moonesinghe, SR, Smart, N, Hinchliffe, R & Grieve, R 2022, 'Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database', Anaesthesia, vol. 77, no. 8, pp. 865-881. https://doi.org/10.1111/anae.15730

TY - JOUR

T1 - Effectiveness of emergency surgery for five common acute conditions

T2 - an instrumental variable analysis of a national routine database

AU - Hutchings, A.

AU - O’Neill, S.

AU - Lugo-Palacios, D.

AU - Moler Zapata, S.

AU - Silverwood, R.

AU - Cromwell, D.

AU - Keele, L.

AU - Bellingan, G.

AU - Moonesinghe, S. R.

AU - Smart, N.

AU - Hinchliffe, R.

AU - Grieve, R.

N1 - Funding Information: The ESORT study is funded by the National Institute for Health Research Health Services and Delivery Research. This report is also independent research supported by the National Institute for Health Research ARC North Thames. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The authors acknowledge the ESORT study's independent advisory group for the helpful discussions: Mr I. Anderson (Chair), Professor Sir N. Black, Mr P. Charlton, Dr N. Gutacker, Professor C. Hewitt, Ms S. Moug and Mr R. Vohra. They also thank those who participated in the patient and public involvement panel for the ESORT study in July 2020 for their helpful thoughts, and they appreciate the work of B. Silver who managed the ESORT study, and C. Snowden who led the patient and public involvement workshops. They thank their colleagues who made time, during the early months of the COVID-19 pandemic, to attend the clinical panels – M. Bedford, N. Blencowe, A. de Beaux, M. Evans, D. Hariharan, D. Harji, M. Lee, S. Lockwood, F. McDermott, S. Moug, D. Vimalachandran and R. Vohra. Further details are available in the Clinical Panel report: https://www.lshtm.ac.uk/media/39151. No other external funding or competing interests declared. Funding Information: This work was supported by the National Natural Science Foundation of China (31572599), Key Special Project for Introduced Talents Team of Southern Marine Science and Engineering Guangdong Laboratory, Guangzhou (GML2019ZD0402) and Shanghai Universities First‐class Disciplines Project of Fisheries. Publisher Copyright: © 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

PY - 2022/5/19

Y1 - 2022/5/19

N2 - The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: −0.73 days (−2.10–0.64) for appendicitis; 0.60 (−0.10–1.30) for gallstone disease; −2.66 (−15.7–10.4) for diverticular disease; −0.07 (−2.40–2.25) for hernia; and 3.32 (−3.13–9.76) for intestinal obstruction. For patients with ‘severe frailty’, mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: −21.0 (−27.4 to −14.6) for appendicitis; −5.72 (−11.3 to −0.2) for gallstone disease, −38.9 (−63.3 to −14.6) for diverticular disease; −19.5 (−26.6 to −12.3) for hernia; and − 34.5 (−46.7 to −22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: −0.18 (−1.56–1.20) for appendicitis; 0.93 (0.48–1.39) for gallstone disease; 5.35 (−2.56–13.28) for diverticular disease; 2.26 (0.37–4.15) for hernia; and 18.2 (14.8–22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.

AB - The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: −0.73 days (−2.10–0.64) for appendicitis; 0.60 (−0.10–1.30) for gallstone disease; −2.66 (−15.7–10.4) for diverticular disease; −0.07 (−2.40–2.25) for hernia; and 3.32 (−3.13–9.76) for intestinal obstruction. For patients with ‘severe frailty’, mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: −21.0 (−27.4 to −14.6) for appendicitis; −5.72 (−11.3 to −0.2) for gallstone disease, −38.9 (−63.3 to −14.6) for diverticular disease; −19.5 (−26.6 to −12.3) for hernia; and − 34.5 (−46.7 to −22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: −0.18 (−1.56–1.20) for appendicitis; 0.93 (0.48–1.39) for gallstone disease; 5.35 (−2.56–13.28) for diverticular disease; 2.26 (0.37–4.15) for hernia; and 18.2 (14.8–22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.

KW - abdominal wall hernia

KW - acute appendicitis

KW - diverticular disease

KW - emergency surgery

KW - gallstone disease

KW - intestinal obstruction

KW - surgery

UR - https://www.scopus.com/pages/publications/85126764079

U2 - 10.1111/anae.15730

DO - 10.1111/anae.15730

M3 - Article (Academic Journal)

C2 - 35588540

AN - SCOPUS:85126764079

SN - 0003-2409

VL - 77

SP - 865

EP - 881

JO - Anaesthesia

JF - Anaesthesia

IS - 8

ER -

Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database

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