Acute Care Surgery Model: High Quality Care for Higher Risk Populations

Introduction: Emergency General Surgery (EGS) represent a wide spectrum of diseases with high complication and mortality rates. Race, insurance, and socioeconomic status have been associated with mortality in EGS patients. Acute care surgery (ACS) models have previously shown improved outcomes for EGS patients. We hypothesized that transition to an ACS model would increase access to care for underserved and higher risk EGS patients in a community hospital, without a change in mortality.

Methods: This retrospective cohort study included adult EGS patients from 2017 to 2021 with current procedural terminology (CPT) codes of colectomy, small-bowel resection, peptic-ulcer surgery, appendectomy, or cholecystectomy. In July 2020, the hospital transitioned from a traditional model to an ACS model. Patients were analyzed for 42-month before (pre-ACS) and 18-month after (post-ACS) transition. Primary outcome was mortality; secondary outcomes were 30-day postoperative emergency department visits and readmission.

Results: We analyzed 467 pre-ACS and 238 post-ACS patients. After transition, patients were more likely to be Black, older, self-pay, and have higher Elixhauser Comorbidity Index (ECI) scores. Rates of cholecystectomies increased and appendectomies decreased after transition. Adjusting for age, race, and ECI, there were no changes in 30-day all-cause mortality (0.9% versus 2.1%, P = 0.63), length of stay (2.7-days versus 3-days, P = 0.91) and rate of postop emergency department visits (7.5% versus 11.3%, P = 0.16). There was a significant increase in hospital readmission after the ACS transition (5.1 versus 10.5%, P = 0.001, odds ratio 5.3).

Conclusions: After implementation of an ACS model, we found an increase in EGS patients who were older, Black, underinsured, with higher ECI without change in mortality. Implementation of ACS models at community hospitals may increase access to quality care for underserved and higher risk patient populations.