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Fewer emergency surgeries, more deaths in British hospitals vs U.S.

(Reuters Health) – When patients in England or the U.S. have abdominal emergencies like appendicitis or a ruptured aneurysm, half as many in England get surgery and many more die, a new study suggests.

Deaths in the hospital were significantly higher in England for all seven types of abdominal emergencies analyzed in the study, suggesting that some of these deaths might be attributable to not having received surgery to correct the problem, researchers write in Annals of Surgery.

Differences between England’s publicly-funded National Health Service and the private medical centers of the U.S. may influence the availability of resources and services, “including life-saving treatment in an emergency setting,” Sheraz R. Markar of Imperial College London and St. George’s University of London and colleagues write.

Past research has found higher mortality rates for several cancers and for hospitalized patients with certain conditions in England compared with the U.S., but these studies have not “clearly identified the differences in clinical practices that are responsible,” the authors note.

They did not respond to requests for comment.

Markar’s team reviewed data from 2006 to 2012 on patients admitted with ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer perforation, small intestine or large intestine perforation, or an incarcerated or strangulated abdominal or groin hernias.

There were 136,047 admissions in England and 1.8 million in the U.S.

“Noncorrective care” – meaning no surgical correction – was more common than surgery for all conditions in England, as were deaths in hospital.

Patients in England, for example, were 4.25 times as likely as those in the U.S. to receive noncorrective care for ruptured aortic aneurysm and 8.53 times as likely with appendicitis.

For a perforated esophagus, 42% of patients in England received noncorrective care compared with 31% in the U.S. The overall hospital mortality rate for this condition was 11% in England versus 6% in the U.S. Patterns were similar for the other conditions.

When researchers looked only at patients who did not receive surgery, death rates were higher in England for four conditions: aortic dissection, peptic ulcer perforation, small bowel or large bowel perforation and incarcerated or strangulated hernias.

Some of the differences between the countries might be explained by factors the study could not measure, the authors acknowledge.

“This type of study contains many potential sources of bias that can mislead the reader into believing results are better in the U.S. than the UK,” said Dr. Derek Alderson, emeritus professor of surgery at the University of Birmingham and president of the Royal College of Surgeons of England.

“The study only looked at ‘in-hospital’ mortality – a term that might mean death within 30 days of surgery or any time during that admission,” Alderson, who was not involved the study, told Reuters Health by email.

“Attitudes to ongoing care and further interventions may well be different in an insurance-led system versus one that is free at the point of access, especially patients who have undergone an intervention,” he added.

The researchers say limited resources in England’s socialized healthcare system could explain a more “frugal approach to utilization of interventional treatment,” but they note they did not look at the role of doctors’ choices about care.

There appears to be a difference in thresholds for surgical intervention in England and the U.S., and factors around this are “extremely complex and cannot be identified by a study of this nature,” the authors write.

Alderson agrees.

“In neither country do we know the numbers of patients who were not admitted to hospitals who died from these conditions,” he told Reuters Health.

“It would be unwise to interpret the data as implying some form of rationing of surgery by surgeons in the UK.”

Societal attitudes, investment in healthcare and resource limitations must all play some part in decisions to intervene, he said.

SOURCE: Annals of Surgery, online October 9, 2019.

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