EP.FRI.752 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology – A Systematic Review

Aims Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions. Methods A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. Results 17 studies were included in the final analysis. 15 unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway. Conclusions There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

Explaining ethnic differentials in COVID-19 mortality: cohort study

Ethnic inequalities in coronavirus disease 2019 (COVID-19) hospitalizations and mortality have been widely reported but there is scant understanding of how they are embodied. The UK Biobank prospective cohort study comprises around half a million people who were aged 40-69 years at study induction between 2006 and 2010 when information on ethnic background and potential explanatory factors was captured. Study members were prospectively linked to a national mortality registry. In an analytical sample of 448,664 individuals (248,820 women), 705 deaths were ascribed to COVID-19 between 5th March, 2020 and 24th January, 2021. In age- and sex-adjusted analyses, relative to White participants, Black study members experienced around five times the risk of COVID-19 mortality (odds ratio; 95% confidence interval: 4.81; 3.28, 7.05), while there was a doubling in the South Asian group (2.05; 1.30, 3.25). Controlling for baseline comorbidities, social factors (including socioeconomic circumstances), and lifestyle indices attenuated this risk differential by 34% in Black study members (2.84; 1.91, 4.23) and 37% in South Asian individuals (1.57; 0.97, 2.55). The residual risk of COVID-19 deaths in ethnic minority groups may be ascribed to a range of unmeasured characteristics and requires further exploration.

Self-Reported Lifetime History of Eating Disorders and Mortality in the General Population: A Canadian Population Survey with Record Linkage

Eating disorders (EDs) are often reported to have the highest mortality of any mental health disorder. However, this assertion is based on clinical samples, which may provide an inaccurate view of the actual risks in the population. Hence, in the current retrospective cohort study, mortality of self-reported lifetime history of EDs in the general population was explored. The data source was the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), linked to a national mortality database. The survey sample was representative of the Canadian household population (mean age = 43.95 years, 50.9% female). The survey inquired about the history of professionally diagnosed chronic conditions, including EDs. Subsequently, the survey dataset was linked to the national mortality dataset (for the date of death) up to 2017. Cox proportional hazards models were used to explore the effect of EDs on mortality. The unadjusted-hazard ratio (HR) for the lifetime history of an ED was 1.35 (95% CI 0.70–2.58). However, the age/sex-adjusted HR increased to 4.5 (95% CI 2.33–8.84), which was over two times higher than age/sex-adjusted HRs for other mental disorders (schizophrenia/psychosis, mood-disorders, and post-traumatic stress disorder). In conclusion, all-cause mortality of self-reported lifetime history of EDs in the household population was markedly elevated and considerably higher than that of other self-reported disorders. This finding replicates prior findings in a population-representative sample and provides a definitive quantification of increased risk of mortality in EDs, which was previously lacking. Furthermore, it highlights the seriousness of EDs and an urgent need for strategies that may help to improve long-term outcomes.

1020 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology

Introduction Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality, and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions. Method A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. Results Eighty-five results were assessed to include 19 papers in the analysis. Fifteen unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway. Conclusions There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

National Excess Mortality from Sub-National data: Method and Application for Argentina

Currently, many countries have not yet reported 2020 or 2021 mortality data to allow an estimate of excess mortality during the COVID-19 pandemic. However, some countries have sub-national mortality data, at the state, province or city level. I present a simple method to allow estimation of national level mortality and excess mortality from sub-national data, using the case of Argentina and projecting excess mortality up to August 2021.

Defining Rural In Aotearoa New Zealand: A Novel Geographic Classification For Health Purposes

Objectives: To develop a valid rurality classification for health purposes in Aotearoa New Zealand (NZ) that is technically robust and incorporates heuristic understandings of rurality.Setting: Our Geographic Classification for Health (GCH) is developed for all of NZ.Participants: We examine the distribution of the entire NZ population across rurality classifications, and use the National Mortality Collection to examine previously masked rural-urban differences in mortality. Outcome measures: Unadjusted all-cause mortality rates and rural:urban incidence rate ratios (IRRs). Results: The GCH modifies key population and drive time thresholds in the generic rurality classifications, thereby identifying 19% of the NZ population as rural. Rural and urban all-cause mortality rates and associated rural:urban IRRs vary considerably depending on rurality classification. The GCH finds a rural mortality rate 21% higher than for urban areas.Conclusions: The GCH identifies a distinct rural population, and highlights rural-urban inequities that are masked by generic classifications.

Functional and Cognitive Impairments Increased Risks of Outcomes of Healthcare Utilization in Patients With Stroke Receiving Home and Community-Based Care in Taiwan

Aim: Stroke is a leading cause of disability; however, little is known about the outcomes of the utilization of long-term care (LTC) recipients in Taiwan. This study aimed to quantify the burdens of disease of stroke survivors receiving LTC by evaluating the outcomes of their utilization including mortality, readmissions, and re-emergency within 1 year after diagnoses of strokes.Methods: By interlinkages among the national mortality registry, LTC dataset (LTC-CM), and the National Health Insurance Research Dataset (NHIRD), the outcomes and the factors associated with receiving LTC up to 1 year were explored. Patients were aged 50 years and over with an inpatient claim of the first diagnosis of stroke of intracerebral hemorrhage (ICH) and ischemic stroke during 2011–2016. Outcomes of the healthcare utilization include rehospitalization and re-emergency.Results: There were 15,662 patients with stroke who utilized the LTC services in the dataset among the stroke population in NHIRD. Stroke survivors receiving LTC showed no difference in clinical characteristics and their expected years of life loss (EYLL = 7.4 years) among those encountered in NHIRD. The LTC recipients showed high possibilities to be rehospitalized and resent to emergency service within 1 year after diagnosis. Apart from the comorbidity and stroke severity, both the physical and mental functional disabilities and caregiving resources predicted the outcomes of the utilization.Conclusions: For stroke survivors, both severe functional impairments and cognitive impairments were found as important factors for healthcare utilizations. These results regarding reserving functional abilities deserve our consideration in making the decision on the ongoing LTC policy reform in the aged society of Taiwan.

Oxygen and Mortality in COVID-19 Pneumonia: A Comparative Analysis of Supplemental Oxygen Policies and Health Outcomes Across 26 Countries

Introduction: Hypoxia is the main cause of morbidity and mortality in COVID-19. During the COVID-19 pandemic, some countries have reduced access to supplemental oxygen, whereas other nations have maintained and even improved access to supplemental oxygen. We examined whether variation in the nationally determined oxygen guidelines had any association with national mortality rates in COVID-19.Methods: Three independent investigators searched for, identified, and extracted the nationally recommended target oxygen levels for the commencement of oxygen in COVID-19 pneumonia from the 29 worst affected countries. Mortality estimates were calculated from three independent sources. We then applied both parametric (Pearson's R) and non-parametric (Kendall's Tau B) tests of bivariate association to determine the relationship between case fatality rate (CFR) and target SpO2, and also between potential confounders and CFR.Results: Of the 26 nations included, 15 had employed conservative oxygen strategies to manage COVID-19 pneumonia. Of them, Belgium, France, USA, Canada, China, Germany, Mexico, Spain, Sweden, and the UK guidelines advised commencing oxygen when oxygen saturations (SpO2) fell to 91% or less. A statistically significant correlation was found between SpO2 and CFR both parametrically (R = −0.53, P < 0.01) and non-parametrically (−0.474, P < 0.01).Conclusion: Our study highlights the disparity in oxygen provision for COVID-19 patients between the nations analysed. In those nations that pursued a conservative oxygen strategy, there was an association with higher national mortality rates. We discuss the potential reasons for such an association.