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Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients
Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

Background: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. Methods: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. Results: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76–0.96; and OR: 0.89; 95% CI: 0.81–0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80–0.99; and OR: 0.89; 95% CI: 0.81–0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01–2.56; and OR: 1.61; 95% CI: 1.08–2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29–0.42; and OR: 0.64; 95% CI: 0.55–0.73, respectively). Conclusions: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.

emergency laparotomy, frailty, health services research, pathological processes, postoperative mortality, surgical procedures
0007-0912
1346-1356
Oliver, C. M.
9bd35fec-7026-47bc-966a-efb8b9fd622e
Bassett, M. G.
bf5514bd-bcfb-4a50-b475-719cbf9d7499
Poulton, T. E.
fc7e8c4f-890c-4de3-9de3-314e011ecadc
Anderson, I. D.
a038c0cc-1c89-401a-8811-e00dd375cb75
Murray, D. M.
7068e97d-ea01-4ca4-b23c-7ffa6c38195d
Grocott, M. P.
1e87b741-513e-4a22-be13-0f7bb344e8c2
Moonesinghe, S. R.
6ff54b33-20ca-45b4-8f5d-636cd3b55749
the National Emergency Laparotomy Audit collaborators
Oliver, C. M.
9bd35fec-7026-47bc-966a-efb8b9fd622e
Bassett, M. G.
bf5514bd-bcfb-4a50-b475-719cbf9d7499
Poulton, T. E.
fc7e8c4f-890c-4de3-9de3-314e011ecadc
Anderson, I. D.
a038c0cc-1c89-401a-8811-e00dd375cb75
Murray, D. M.
7068e97d-ea01-4ca4-b23c-7ffa6c38195d
Grocott, M. P.
1e87b741-513e-4a22-be13-0f7bb344e8c2
Moonesinghe, S. R.
6ff54b33-20ca-45b4-8f5d-636cd3b55749

Oliver, C. M., Bassett, M. G., Poulton, T. E., Anderson, I. D., Murray, D. M., Grocott, M. P. and Moonesinghe, S. R. , the National Emergency Laparotomy Audit collaborators (2018) Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients. British Journal of Anaesthesia, 121 (6), 1346-1356. (doi:10.1016/j.bja.2018.07.040).

Record type: Article

Abstract

Background: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. Methods: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. Results: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76–0.96; and OR: 0.89; 95% CI: 0.81–0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80–0.99; and OR: 0.89; 95% CI: 0.81–0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01–2.56; and OR: 1.61; 95% CI: 1.08–2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29–0.42; and OR: 0.64; 95% CI: 0.55–0.73, respectively). Conclusions: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.

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More information

Accepted/In Press date: 22 July 2018
e-pub ahead of print date: 3 October 2018
Published date: December 2018
Keywords: emergency laparotomy, frailty, health services research, pathological processes, postoperative mortality, surgical procedures

Identifiers

Local EPrints ID: 427326
URI: http://eprints.soton.ac.uk/id/eprint/427326
ISSN: 0007-0912
PURE UUID: 9b49623d-92f5-467d-88f2-2c02c3f09db6
ORCID for M. P. Grocott: ORCID iD orcid.org/0000-0002-9484-7581

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Date deposited: 11 Jan 2019 17:30
Last modified: 07 Oct 2020 01:56

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Contributors

Author: C. M. Oliver
Author: M. G. Bassett
Author: T. E. Poulton
Author: I. D. Anderson
Author: D. M. Murray
Author: M. P. Grocott ORCID iD
Author: S. R. Moonesinghe
Corporate Author: the National Emergency Laparotomy Audit collaborators

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