Introduction: The Evolution of Emergency General Surgery
Emergency general surgery (EGS) represents a significant portion of the global surgical burden, encompassing a wide range of conditions from simple appendicitis to life-threatening mesenteric ischemia. Historically, EGS has been managed through a traditional surgeon on-call (SOC) model, where a general surgeon manages emergency admissions alongside a full schedule of elective surgeries and outpatient clinics. This model, however, has long been criticized for potential delays in care, surgeon fatigue, and fragmented perioperative management.
In response, many healthcare systems have transitioned toward dedicated EGS models, often referred to as Acute Care Surgery (ACS) models. These specialized systems typically involve dedicated surgical teams, prioritized operating room access, and standardized clinical pathways. While institutional studies have suggested benefits, large-scale, population-level evidence remains sparse, particularly regarding whether these models benefit all patients or only those with the highest acuity. A recent study by Nantais et al., published in JAMA Surgery, provides a comprehensive evaluation of these care models using nearly two decades of population-level data from Ontario, Canada.
Highlights of the Study
The study provides critical insights into the efficacy of EGS models, with several key takeaways for clinicians and health administrators:
- EGS models are associated with a 15% reduction in 30-day mortality for high-risk surgical conditions.
- The odds of complications for high-risk patients were 32% lower in hospitals utilizing a dedicated EGS model.
- Patients with low- or medium-risk conditions did not show a statistically significant improvement in outcomes when treated in an EGS model compared to the traditional SOC model.
- The findings support the regionalization of high-risk emergency surgical care to centers with dedicated EGS resources.
Study Design and Methodology
This retrospective cohort study utilized linked administrative data from ICES (formerly the Institute for Clinical Evaluative Sciences) in Ontario, Canada. The researchers examined data for adults hospitalized with one of nine common EGS conditions between April 1, 2002, and December 31, 2019. The nine conditions included appendicitis, cholecystitis, diverticulitis, hernias, intestinal obstruction, perforated peptic ulcer, mesenteric ischemia, soft tissue infections, and upper gastrointestinal bleeding.
The primary exposure was treatment at a hospital with an EGS model of care versus a standard SOC model. The EGS model was defined by the presence of dedicated personnel and resources specifically allocated for emergency surgical patients. To ensure a robust analysis, the researchers used generalized estimating equations (GEE) to account for hospital-level clustering and adjusted for a wide array of patient comorbidities and demographic factors.
A distinctive feature of this study was the stratification of patients into three risk categories—low, medium, and high—based on the baseline mortality risk of their diagnosis. This allowed the researchers to identify which patient populations derived the most benefit from specialized care models.
Key Findings: Mortality and Complications
A total of 494,609 patients were included in the analysis, with 18% (88,889) treated in an EGS model hospital. The results demonstrated a clear divergence in outcomes based on patient risk profiles.
High-Risk Patients: The Primary Beneficiaries
For patients with high-risk conditions (such as mesenteric ischemia or perforated peptic ulcer), the EGS model was strongly associated with improved survival. The adjusted relative risk (aRR) of death within 30 days was 0.85 (95% CI, 0.77-0.95). This benefit persisted at the 90-day mark, with an aRR of 0.82 (95% CI, 0.74-0.92). Furthermore, the odds of experiencing a major complication were significantly lower (adjusted odds ratio [aOR], 0.68; 95% CI, 0.53-0.87).
Low- and Medium-Risk Patients
Interestingly, the study found no significant association between the EGS model and 30-day mortality for patients with low-risk conditions (aRR, 1.09; 95% CI, 0.84-1.42) or medium-risk conditions (aRR, 0.96; 95% CI, 0.88-1.04). This suggests that for common, lower-acuity conditions like uncomplicated appendicitis, the traditional on-call model remains effective, provided standard surgical care is available.
Failure to Rescue and Readmissions
The study also examined “failure to rescue” (death following a major complication) and 30-day readmission rates. Surprisingly, there was no significant difference in failure to rescue between the two models. This implies that the primary benefit of the EGS model lies in the prevention of complications through better initial management and timely intervention, rather than an improved ability to manage complications once they occur.
Expert Commentary and Clinical Implications
The findings by Nantais et al. have significant implications for the organization of surgical services. The data suggests that dedicated EGS models provide a specialized environment that is particularly adept at managing the complexity of high-risk patients. This likely stems from several factors: dedicated operating room time reducing the time-to-surgery, specialized nursing staff familiar with acute surgical pathology, and the presence of surgeons who focus exclusively on the emergency patient population.
From a health policy perspective, these results argue for a “hub-and-spoke” regionalization strategy. Under such a system, high-risk EGS cases would be prioritized for transfer to specialized EGS centers, while low-risk cases could continue to be managed at local community hospitals. This approach would optimize resource allocation, ensuring that the most intensive resources are directed toward the patients most likely to benefit from them.
However, the study also highlights the challenges of implementing EGS models. Establishing such a model requires significant investment in personnel and infrastructure. Hospitals must weigh these costs against the potential for improved outcomes and reduced long-term morbidity in their highest-risk populations.
Limitations and Future Directions
While the study is robust due to its large sample size and population-level scope, it is not without limitations. As a retrospective administrative data study, it may be subject to residual confounding. Additionally, the definition of an “EGS model” can vary between institutions, and the study could not account for all nuances of how these models were implemented on the ground. Future research should focus on the specific components of the EGS model—such as the role of multidisciplinary teams or specific clinical pathways—to determine which elements contribute most to the observed improvements in survival.
Conclusion
The study by Nantais and colleagues provides compelling evidence that dedicated emergency general surgery models of care are associated with significantly lower mortality and complication rates for high-risk patients. While low-risk patients may not see a measurable difference in outcomes, the survival benefit for the most critically ill surgical patients is substantial. These findings provide a data-driven foundation for health systems to refine their emergency surgical care delivery, prioritizing the regionalization of high-risk EGS care to improve population health outcomes.
References
Nantais J, Saskin R, Calzavara A, Gomez D, Baxter NN. A Population-Level Evaluation of Emergency General Surgery Models of Care and Clinical Outcomes. JAMA Surg. 2026 Jan 21:e256155. doi: 10.1001/jamasurg.2025.6155. Epub ahead of print. PMID: 41563736.
