Shahid Shafi M.D.

Ogola, G. O., M. L. Crandall and S. Shafi (2018). “High Volume Hospitals are Associated with Lower Mortality among High-risk Emergency General Surgery Patients.” J Trauma Acute Care Surg. May 21. [Epub ahead of print].

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INTRODUCTION: We have previously demonstrated that Emergency General Surgery (EGS) patients treated at high-volume hospitals experience lower mortality rates than those treated at low-volume hospitals. However, EGS comprises a wide spectrum of diseases. Our goal was to determine which EGS diseases had better outcomes at high volume hospitals. METHODS: We undertook a retrospective analysis of National Inpatient Sample database for 2013 (a nationwide representative sample). Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to measure risk-adjusted probability of death, adjusting for age, sex, race, ethnicity, insurance type, and comorbidities. Patients were then grouped into 16 risk groups based upon their predicted probability of death. We then compared observed mortality rates at high vs. low-volume hospitals within each risk-group. RESULTS: Nationwide, 3,006,615 patients with EGS diseases were treated at 4,083 hospitals in 2013. Patients with predicted risk of death of 4% or higher (275,615 patients, 9.2%) had lower observed mortality rates at high volume hospitals compared to low volume hospitals (7.7% versus 10.2%, p<0.001). We estimated that 1002 deaths were potentially preventable if high-risk patients that were treated in low-volume hospitals were instead transferred to high-volume hospitals. CONCLUSION: EGS patients with predicted risk of death of 4% or higher have experience lower mortality rates at high volume hospitals compared to low volume hospitals. A regional system of EGS care that enables rapid transfer of high risk patients to high volume hospitals may prevent several deaths. LEVEL OF EVIDENCE: Level III STUDY TYPE: prognostic and epidemiological.

Hernandez, M., J. Havens, S. Shafi and M. Crandall (2018). “Risk Assessment in Emergency General Surgery.” J Trauma Acute Care Surg. Mar 12. [Epub ahead of print].

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Patients with emergency general surgery (EGS) diseases display variable severity. The extent of disease can be amplified by comorbidity or dramatic changes in presenting physiology. Estimating the extent of disease severity in order to adequately provide prognosis, determine optimal operative or non-operative management, and plan for potential outcomes is difficult. A variety of risk factors have been studied for specific diseases but these criteria may not be universally applied. This limits the generalizability of prior work. The American Association for the Surgery of Trauma (AAST) created a grading system wherein uniform definitions could be applied to begin to measure disease severity in a granular manner. This review presents some of the initial work focused on the validation and incorporation of the AAST EGS grading system. The authors evaluate several diseases wherein the AAST EGS grade has been applied. Finally the work concludes with a review of several inclusive risk estimation tools. Taken together, the ability to measure disease severity – whether by anatomic changes, physiologic disturbance, or patient comorbidity status – will provide a better method to appraise, research, and improve patient care for several EGS conditions.

Ogola, G. O., M. L. Crandall and S. Shafi (2018). “Variations in outcomes of emergency general surgery patients across hospitals: A call to establish emergency general surgery quality improvement program.” J Trauma Acute Care Surg 84(2): 280-286.

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BACKGROUND: National Surgical Quality Improvement Program and Trauma Quality Improvement Program have shown variations in risk-adjusted outcomes across hospitals. Our study hypothesis was that there would be similar variation in risk-adjusted outcomes of emergency general surgery (EGS) patients. METHODS: We undertook a retrospective analysis of the National Inpatient Sample database for 2010. Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to model in-hospital mortality, accounting for patient characteristics, including age, sex, race, ethnicity, insurance type, and comorbidities. Predicted-to-expected mortality ratios with 90% confidence intervals were used to identify hospitals as low mortality (ratio significantly lower than 1), high mortality (ratio significantly higher than 1), or average mortality (ratio overlapping 1). RESULTS: Nationwide, 2,640,725 patients with EGS diseases were treated at 943 hospitals in 2010. About one-sixth of the hospitals (139, 15%) were low mortality, a quarter were high mortality (221, 23%), and the rest were average mortality. Mortality ratio at low mortality hospitals was almost four times lower than that of high mortality hospitals (0.57 vs. 2.03, p < 0.0001). If high and average mortality hospitals performed at the same level as low mortality hospitals, we estimate 16,812 (55%) more deaths than expected. CONCLUSION: There are significant variations in risk-adjusted outcomes of EGS patients across hospitals, with several thousand higher than expected number of deaths nationwide. Based on the success of National Surgical Quality Improvement Program and Trauma Quality Improvement Program, we recommend establishing EGS quality improvement program for risk-adjusted benchmarking of hospitals for EGS patients. LEVEL OF EVIDENCE: Care management, level III.

Ogola, G. O., M. L. Crandall and S. Shafi (2017). “Variations in outcomes of emergency general surgery patients across hospitals: A call to establish emergency general surgery quality improvement program (eqip).” J Trauma Acute Care Surg: 2017 Nov [Epub ahead of print].

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BACKGROUND: National Surgical Quality Improvement Program (NSQIP) and Trauma Quality Improvement Program (TQIP) have shown variations in risk-adjusted outcomes across hospitals. Our study hypothesis was that there would be similar variation in risk-adjusted outcomes of Emergency General Surgery (EGS) patients. METHODS: We undertook a retrospective analysis of the National Inpatient Sample database for 2010. Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to model in-hospital mortality, accounting for patient characteristics, including age, sex, race, ethnicity, insurance type, and comorbidities. Predicted-to-Expected mortality ratios with 90% confidence intervals, were used to identify hospitals as low mortality (ratio significantly lower than 1), high mortality (ratio significantly higher than 1), or average mortality (ratio overlapping 1). RESULTS: Nationwide, 2,640,725 patients with EGS diseases were treated at 943 hospitals in 2010. About one-sixth of the hospitals (139, 15%) were low mortality, a quarter were high mortality (221, 23%), while the rest were average mortality. Mortality ratio at low mortality hospitals was almost four times lower than that of high mortality hospitals (0.57 vs. 2.03, p < .0001). If high and average mortality hospitals performed at the same level as low mortality hospitals, we estimate 16,812 (55%) more deaths than expected. CONCLUSION: There are significant variations in risk-adjusted outcomes of EGS patients across hospitals, with several thousand higher than expected number of deaths nationwide. Based upon the success of NSQIP and TQIP, we recommend establishing EGS Quality Improvement Program (EQIP) for risk-adjusted benchmarking of hospitals for EGS patients.

Zogg, C. K., W. Jiang, T. D. Ottesen, S. Shafi, K. Schuster, R. Becher, K. A. Davis and A. H. Haider (2017). “Racial/ethnic disparities in longer-term outcomes among emergency general surgery patients: The unique experience of universally insured older adults.” Ann Surg: 2017 Jul [Epub ahead of print].

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OBJECTIVES: To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (>/=65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital’s percentage of minority patients. SUMMARY OF BACKGROUND DATA: As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients’ postacute recovery period among older adults. METHODS: Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models. RESULTS: A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86-0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98-1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups. CONCLUSION: The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.