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Effect of Admission Service on Clinical Outcomes and Cost in Patients With Small Bowel Obstruction
Laura a. Allen*, Laura a. Graham, Allison a. Gullick, Mary T. Hawn
Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL
Small bowel obstruction (SBO) is a complication of previous abdominal surgeries, hernias, and other pathologies. Patients can be managed non-operatively or operatively, thus patients are admitted to medical and surgical services. The purpose of this study was to compare characteristics and outcomes associated with admitting service.
A retrospective medical record review was conducted of SBO admissions via the emergency department to an academic medical center in 2012. Patients were identified using discharge diagnosis codes in an administrative database. Patients with ileus without mechanical obstruction, lack of obstructive symptoms, and previous abdominal surgery within 30 days were excluded (103 patients with 107 admissions). Univariate and bivariate frequencies were used to describe the population. Chi-square and Wilcoxon rank sums tests were used to examine differences by admission service.
251 patients with 292 admissions were included in the analysis. Approximately half (n=134; 46%) were admitted to medical services; there was no difference in age, sex, race, insurance status, or comorbidities between patients admitted to medicine vs. surgery. The most common etiologies were adhesive disease (60%) and hernias (16%). 205 admissions (70%) were managed non-operatively; 113 (55%) were admitted to medical and 92 (45%) were admitted to surgical services. There was no difference in time to bowel function, use of total parenteral nutrition (TPN), 30-day readmission rates, or mortality for patients managed on medical vs. surgical services (Table 1). Non-operative surgical admissions were associated with lower cost despite equivalent hospital length of stay (LOS). 87 admissions (30%) were managed operatively; 21 (24%) were admitted to medical and 66 (76%) were admitted to surgical services. Time from admission to operation was shorter for patients admitted to surgery (median, 0.9 days; IQR, 0.4-3.6) than medicine (median, 4.6 days; IQR 2.2-8.3; p=0.0002); this held true when excluding patients that were operated on within 24 hours of admission (median, 3.7 days vs. 5.0; p=0.08). Operative intervention in patients admitted to medical services was more likely to require a bowel resection (n=13; 62%) than surgical admissions (n=18; 27%; p=0.004). Major complications and mortality were also more frequent in medical (n=8; 42%) than surgical admissions (n=7; 15%; p=0.02). Surgical admissions were associated with shorter hospital and post-operative LOS, less TPN use, lower mortality, and lower cost (Table 2).
Patients admitted with SBO were managed more efficiently when admitted to surgical services regardless of whether surgical intervention was required. Furthermore, patients admitted to the medical service that required surgical intervention had worse outcomes. These data support routine admission to surgical services for patients presenting with SBO. Table 1. Outcomes of Non-Operative Management by Admit Service | Overall | Medicine Service | Surgery Service | P Value | | Number of Admissions [No. (%)] | 205 | 113 (55%) | 92 (45%) | | | Time to Bowel Movement [Median (IQR)] | 1 (1-2) | 1 (1-2) | 1 (1-2) | 0.58 | | Time to Tolerating Clear Liquids [Median (IQR)] | 2 (1-3) | 2 (1-3) | 2 (1-3) | 0.78 | | Total Parenteral Nutrition [No. (%)] | 11 (5.4%) | 4 (3.5%) | 7 (7.6%) | 0.20 | | Mortality [No. (%)] | 11 (5.4%) | 8 (7.1%) | 3 (3.3%) | 0.23 | | Total Length of Stay [Median (IQR)] | 4 (3-7) | 4 (3-7) | 4 (3-5) | 0.23 | | Total Cost [Median (IQR)] | $4,479 (3,301-7,347) | $4,754 (3,510-8,249) | $3,904 (3,025-6,275) | 0.01 | | Readmission Within 30 Days [No. (%)] | 59 (29%) | 28 (25%) | 31 (34%) | 0.16 | | Related Readmission Within 30 Days [No. (%)] | 36 (17%) | 14 (12%) | 22 (24%) | 0.03 |
Table 2. Outcomes of Operative Management by Admit Service | Overall | Medicine Service | Surgery Service | P Value | | Number of Admissions [No. (%)] | 87 | 21 (24%) | 66 (76%) | | | Surgical Complications [No. (%)] | 67 (77%) | 19 (90%) | 48 (73%) | 0.09 | | Grade I/II | 44 (66%) | 11 (58%) | 33 (69%) | 0.02 | | Grade III | 8 (12%) | 0 | 8 (17%) | | Grade IV/V | 15 (22%) | 8 (42%) | 7 (15%) | | Time to Bowel Movement [Median (IQR)] | 5 (3-8) | 6 (3-11) | 5 (3-7) | 0.29 | | Time to Tolerating Clear Liquids [Median (IQR)] | 5 (2-8) | 6 (3-12) | 4 (2-7) | 0.05 | | Total Parenteral Nutrition [No. (%)] | 28 (32%) | 12 (57%) | 16 (24%) | 0.01 | | Mortality [No. (%)] | 5 (5.8%) | 4 (19%) | 1 (1.5%) | 0.003 | | Total Length of Stay [Median (IQR)] | 8 (5-15) | 15 (10-21) | 7 (4-12) | 0.0003 | | Post-Operative Length of Stay [Median (IQR)] | 7 (4-10) | 9 (5-13) | 6 (3-9) | 0.02 | | Total Cost [Median (IQR)] | $15,331 (10,794-29,411) | $29,936 (18,165-41,130) | $14,411 (8,976-25,339) | 0.0004 | | Readmission Within 30 Days [No. (%)] | 27 (31%) | 8 (38%) | 19 (29%) | 0.42 | | Related Readmission Within 30 Days [No. (%)] | 15 (17%) | 4 (19%) | 11 (17%) | 0.80 |
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