Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team

Abstract

Objective: To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions.

Summary background data: Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies.

Methods: Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions.

Results: Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32).

Conclusions: This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.