Small Bowel Obstruction Is a Surgical Disease: Patients with Adhesive Small Bowel Obstruction Requiring Operation Have More Cost-Effective Care When Admitted to a Surgical Service - 19/06/15

Doi : 10.1016/j.jamcollsurg.2015.03.054

Phillip A. Bilderback, MD ^⁎ , John D. Massman, PhD, Ryan K. Smith, BA, Danielle La Selva, BA, W. Scott Helton, MD, FACS
Department of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA

^∗Correspondence address: Phillip A Bilderback, MD, Graduate Medical Education, Mail Stop: H8-GME, 925 Seneca St, Seattle, WA 98101.

Abstract

Background

Adhesive small bowel obstruction (ASBO), although a potential surgical emergency, is increasingly being managed by medical hospitalists due to the likelihood these patients will not require operation. However, the value of care delivered by medical hospitalists to patients with ASBO has not been reported.

Study Design

We hypothesized that patients admitted to the medical hospitalist service (MHS) for presumed ASBO have increased length of stay (LOS) and charges compared with patients admitted to the surgical service (SS). There were 555 consecutive admissions with presumed ASBO from 2008 to 2012; these were reviewed and grouped according to admitting service and whether an operation was performed. Group medians were compared and multivariate analysis was performed to identify variables independently associated with increased LOS, time to operation (TTO), and charges.

Results

Median LOS among patients whose ASBO resolved nonoperatively was similar for those on SS and MHS (2.85 days vs 2.98 days; p = 0.49). In patients without nonoperative resolution of ASBO, those admitted to MHS had longer median LOS when compared with those admitted to SS (9.57 days vs 6.99 days; p = 0.002) and higher median charges ($38,800 vs $30,100; p = 0.025). Patients admitted to MHS who had an operation, had a greater median TTO than operative patients on SS (51.72 hours vs 8.4 hours; p < 0.001). Multivariate analysis did not identify factors independently predictive of increased LOS, TTO, or charges.

Conclusions

Adhesive small bowel obstruction patients are treated in a heterogeneous fashion in our hospital, causing disparate outcomes depending on admitting service when patients undergo operation. Admitting all suspected ASBO patients to SS has the potential to dramatically decrease LOS and reduce waste in those requiring operation, thereby reducing health care expenditures.

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Abbreviations and Acronyms : ASBO, IQR, LOS, MHS, SS, TTO