This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
People with severe levels of frailty who are admitted to hospital as emergencies with severe problems of the digestive tract (gut), may not benefit from emergency surgery. Research found that this group of people had worse outcomes with emergency surgery than with other interventions. Alternatives, including drug treatment and surgery at a later date, were more effective and cost less.
Researchers analysed more than 887,000 patient records for people with a severe gut condition admitted to hospital as an emergency. Overall, for each condition, emergency surgery was no more effective or cost-effective than other approaches. However, for people with severe frailty, outcomes were worse following emergency surgery than alternative approaches. For people without frailty, emergency surgery was cost-effective for all conditions, and gave better outcomes for blocked bowel.
Rates of emergency surgery vary between hospitals. This study set out to clarify whether emergency surgery improves outcomes or is more cost-effective than other approaches to care.
This research supports the NHS recommendation for people admitted as emergencies to have a frailty assessment. It could inform service providers, patients, and carers about the relative benefits and risks of emergency surgery compared with other strategies.
For more information about gastrointestinal surgery, visit the NHS website.
The issue: is emergency surgery necessary for severe digestive disorders?
Many people with digestive disorders that start suddenly (acute conditions) are admitted to hospital as an emergency. In England, just over half of these people have emergency surgery within days of their admission. The rest receive alternative treatments, such as medicines, later surgery or minimally invasive procedures guided by scans.
Age UK describes frailty as a person’s ability to bounce back and recover from illnesses and injury; it is a measure of their mental and physical resilience. People with frailty often have fatigue and reduced muscle strength. The condition becomes more common with age, and up to half of those over 85 years, live with frailty.
Hospitals vary considerably in which approach is taken. It is unclear which offers the greatest benefits and whether certain groups of people (such as those with severe frailty) benefit more or less from emergency surgery.
In this study, researchers explored whether emergency surgery was more effective than other approaches for people with 5 common digestive disorders. They compared value for money and looked at the impact of people’s general health, including their level of frailty.
What’s new?
The study investigated treatments for 5 conditions of the gut: diverticular disease (inflamed pockets in the lining of the bowel), cholelithiasis (swelling of the gallbladder), appendicitis, abdominal wall hernia and blocked bowel. Researchers analysed 887,000 patient records for emergency admissions to 175 hospitals in England, between April 2010 and December 2019.
Researchers analysed how long people spent out of hospital (alive) in the 90 days after they first saw a surgeon. Groups of people, such as those with frailty and those with multiple long-term conditions, were considered separately. Costs were analysed after 1 year.
The study found that:
- overall, outcomes and costs were similar, whether people had emergency surgery or another approach to care (such as drug treatment or surgery at a later date)
- for people with severe frailty, alternatives to emergency surgery reduced the number of days spent in hospital, and reduced costs
- for people with a blocked bowel who were not frail, emergency surgery reduced the days spent in hospital, and reduced costs, compared to alternative approaches.
Results for people with long term-conditions were mixed. For example, alternative approaches were more cost-effective for those with cholelithiasis, appendicitis, or a hernia who had long-term conditions. Emergency surgery was more cost-effective for those with diverticular disease or a blocked bowel who had long-term conditions.
Why is this important? Different groups benefitted from different approaches
Overall, for the 5 conditions in this study, emergency surgery was as effective, and as cost-effective, as alternative treatments. The exceptions were people with severe frailty who benefitted more from alternative approaches; and those with a bowel obstruction who were not frail, who benefitted more from emergency surgery.
This evidence could be useful for service providers, and inform discussions between patients, carers and clinicians.
One limitation is that the study only included the costs of people’s stay in hospital. Outpatient visits and care home stays were not considered, which could have had an impact on the results.
What’s next?
This study emphasises the need for frailty assessments as part of preoperative checks for emergency admissions for acute conditions. These assessments could identify people who would benefit more from other approaches to care such as medical treatment or later surgery.
For people with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery. For these people, the researchers say later surgery could be more beneficial than emergency surgery. Delaying surgery allows time to make sure the management of long-term conditions is appropriate, to enable people to benefit from surgery.
The approach taken in this study could be used compare treatments for other acute conditions. This could help the NHS to prioritise resources for the people most likely to benefit from them.
You may be interested to read
This Alert is based on: Grieve R, and others. Clinical effectiveness and cost-effectiveness of emergency surgery for adult emergency hospital admissions with common acute gastrointestinal conditions: the ESORT study. Health and Social Care Delivery Research 2023;11: 1-166.
Information about frailty from Age UK.
Information about taking part in ongoing NIHR research involving digestive disorders.
Funding: This study was supported by the NIHR Health and Social Care Delivery Research Programme.
Conflicts of Interest: One of the authors has received fees from pharmaceutical companies for speaking at events regarding hernia surgery. More details are available in the original paper.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
