Reply to: "A Comparison of Mortality Following Emergency Laparotomy Between Populations From New York State and England".

Reply: We read this article by Tan et al 1 with interest and wish to seek clarification on a number of points presented. The authors highlight a higher crude mortality rate after emergency laparotomy in England only in the older age group. Patients below the age of 55 fair as well if not better in the United Kingdom given the data presented in the article. In the elderly group this may be because of a lower number of critical care beds in England and the impact of the elderly care physicians in New York State. However, we disagree with the statement that outcomes should be the same despite less resources and expenditure, given that according to The Kings Fund the United Kingdom spends 9% of GDP on healthcare compared with over 16% in the United States. Failure to rescue from complications is acknowledged to account for a significant proportion of the difference in mortality rate between centers and has been demonstrated to rely on costly resources such as nursing levels and technology available. Although the authors have correctly referenced the ongoing NELA project in England, they have not discussed the ELPQuiC Study, which demonstrated mortality rates of 9.6%. This care package is now widely adopted in England and one would expect survival improvements to follow. The suggestion that patients are well matched is questionable as only 5.7% of emergency laparotomies in New York State were performed for perforation as opposed to 24.2% in the United Kingdom. The NELA data found a 15% mortality rate for perforation. The English data also had larger cohorts of patients with malignancy and obstruction with 6.9% of patients coded as ‘‘other’’ compared with 14.3% in New York State. We wondered what conditions fall under ‘‘other,’’ that are not benign, malignant, trauma or perforation? This lack of clarity in coding makes it difficult to make confident interpretations on outcome. The authors use the Charlson Co morbidity Index (CCI) in the 30-day mortality table. This chronic health index is a predictor of mortality at 1 year and does not reflect the physiology of the patient in the perioperative period. Although CCI has some association with emergency outcomes P-POSSUM or a similar acute physiology score perhaps would have been more appropriate. The question of what defines a teaching hospital in an important one, as the mortality rate is more than four times higher in nonteaching institutions in England as compared with just over twice as high in New York State. It is apparent from the funnel plot that many of the institutions in New York State perform less than 50 emergency laparotomies per year with a bare minimum of English hospitals in that category. Some of the New York State units demonstrate a mortality rate of more than zero but less than 5% with less than 10 patients suggesting very small practices. The authors highlight a higher weekend mortality rate in English hospitals; however, there does not seem to be statistical analysis to prove this. This topic is highly controversial in the United Kingdom and we believe claims of higher weekend mortality need to be clearly demonstrated. Overall, we endorse the need for improved intensive care access in England as highlighted in the NELA/ELPQuiC studies. However given the limited data on demographics and pathology, we do not accept that the crude mortality rates presented are an accurate reflection of emergency surgical care in either region.