Consequences of Patient-Directed Bypass of Local Surgical Care: A Multistate Analysis

BACKGROUND: Patients bypass their locally available surgical care (bypass) for urgent and emergent surgical diseases, and single-state studies have demonstrated that bypass is associated with worse clinical outcomes. The current study tested this association in a multistate cohort. STUDY DESIGN: This is a retrospective cohort study of 22,902 patients from Arizona, Iowa, North Carolina, Wisconsin, and Vermont who underwent urgent or emergent abdominal surgery in 2019. "Nearest surgical hospitals" (NSH) were defined as those (1) nearest to the patient's ZIP Code Tabulation Area centroid and (2) where standard general surgery procedures were performed. Bypass was defined as a patient going to another hospital at least 10 miles more distant than their NSH. Outcomes of interest included disease complexity, in-hospital mortality, complications, prolonged length of stay, and subsequent transfer to another hospital. RESULTS: Patients who bypassed their NSH did not have significantly increased odds of mortality (adjusted odds ratio [aOR] 1.25, 95% CI 0.87 to 1.80) but did have significantly increased odds of presenting with disease progression (aOR 1.22, 95% CI 1.04 to 1.43). Controlling for disease progression, bypass patients had lower odds of transfer (aOR 0.52, 95% CI 0.31 to 0.89), increased odds of complications (aOR 1.12, 95% CI 1.01 to 1.25), and increased odds of prolonged length of stay (aOR 1.20, 95% CI 1.04 to 1.37). These results persisted across stricter bypass definitions. CONCLUSIONS: In this multistate cohort of patients requiring urgent and emergent surgery, bypassing the nearest available surgical care was associated with worse clinical outcomes. Building systems to support early local intervention for urgent and emergent surgical diseases is critical.