Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call?

Background: Hospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown. Methods: We performed an analysis of the Florida State Inpatient Database (2010–2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived. Results: Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes. Conclusions: Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures.