1. Implementation of an acute care surgery service at a non-trauma hospital resulted in improved outcomes and finances and is sustainable over time.
2. First reported study to show decreased cost to payers and decreased hospital charges utilizing an acute care surgery service.
Evidence Rating Level: 2 (Good)
Study Rundown: In a health-care system where cost of care is a major challenge for sustainability, we are increasingly in need of collaborative care models that may optimize patient care. Acute care surgery (ACS) services replace the model of the on-call surgeon and places a dedicated team that oversees all emergency room patients on a point of care basis making decisions very quickly on whether or not to operate. In this study, 2634 patients underwent operations using the ACS service with an estimated annual savings of 2 million dollars while decreasing hospital length of stay (LOS) by 12%, decreasing rate of complications by 42.8%, and preserving operative volume for non-acute care surgeons.
The strengths of this study include using a large sample database from one hospital and following annual trends for 5 years for a risk adjusted patient population. A limitation of this review is the failure to demonstrate that the total cost of the ACS system, including employee salaries, is less than the previous on-call model. Cost savings with ACS are confounded by the pressures on the hospital during the economic recession which may have already led to other cost-saving measures. Additional limitations include using broad definitions of complications and assessing them retrospectively from hospital records. A prospective trial would provide more specific information on the exact nature and severity of complications as they occur.
In-Depth [retrospective cohort]: This study assessed operative outcomes, costs, and complications at a single tertiary care community hospital between 2007-2011. Data prior to ACS implementation (pre-ACS 2007) was compared to each year after ACS implementation(ACS-1 2008, ACS-2 2009, ACS-3 2010 and ACS-4 2011). The results are presented as a trend over five years. This study demonstrates fewer overall complications with ACS (21% to 12%, p<0.0001), and a shorter length of stay (6.5 days to 5.7 days, p=0.0016). Hospital costs fell from $12,009 to $8,306 (p<0.0001). Post-appendectomy complications decreased (13% to 3.7%, p<0.0001), length of stay was shorter (3.0 to 2.3 days, p<0.0001), and hospital costs decreased from $9,392 to $5,872 (p<0.0001). Post-cholecystectomy complications decreased (21% to 9%, p=0.012), length of stay was shorter (5.3 to 3.8 days, p=0.0004), and hospital costs decreased from $12,526 to $9,348 (p<0.0001). Initially however, in ACS-1, the re-operation rate doubled (3.6% to 6.4%) and the mortality rate tripled (1.4% to 4.1%) before the trends reversed in ACS-3. Also, pre-ACS had nine surgeons who performed 256+/- 130 operations annually and after ACS the range was between a low of 256 and a high of 282. Also to note, no new surgeons started practice at this facility during the study years.
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