ORIGINAL ARTICLE

The public health burden of emergency general surgery in the

United States: A 10-year analysis of the Nationwide Inpatient
SampleV2001 to 2010
Stephen C. Gale, MD, Shahid Shafi, MD, MPH, Viktor Y. Dombrovskiy, MD, MPH, PhD,
Dena Arumugam, MD, and Jessica S. Crystal, MD, Tyler, Texas

BACKGROUND: Emergency general surgery (EGS) represents illnesses of very diverse pathology related only by their urgent nature. The
growth of acute care surgery has emphasized this public health problem, yet the true ‘‘burden of disease’’ remains unknown.
Building on efforts by the American Association for the Surgery of Trauma to standardize an EGS definition, we sought to
describe the burden of disease for EGS in the United States. We hypothesize that EGS patients represent a large, diverse, and
challenging cohort and that the burden is increasing.
METHODS: The study population was selected from the Nationwide Inpatient Sample, 2001 to 2010, using the AAST EGS DRG In-
ternational Classification of DiseasesV9th Rev. codes, selecting all EGS patients 18 years or older with urgent/emergent
admission status. Rates for operations, mortality, and sepsis were compiled along with hospital type, length of stay, insurance,
and demographic data. The W2 test, the t test, and the Cochran-Armitage trend test were used; p G 0.05 was significant.
RESULTS: From 2001 to 2010, there were 27,668,807 EGS admissions, 7.1% of all hospitalizations. The population-adjusted case rate for
2010 was 1,290 admissions per 100,000 people (95% confidence interval, 1,288.9Y1,291.8). The mean age was 58.7 years;
most had comorbidities. A total of 7,979,578 patients (28.8%) required surgery. During 10 years, admissions increased by
27.5%; operations, by 32.3%; and sepsis cases, by 15% ( p G 0.0001). Mortality and length of stay both decreased ( p G 0.0001).
Medicaid and uninsured rates increased by a combined 38.1% ( p G 0.0001). Nearly 85% were treated in urban hospitals, and
nearly 40% were treated in teaching hospitals; both increased over time ( p G 0.0001).
CONCLUSION: The EGS burden of disease is substantial and is increasing. The annual case rate (1,290 of 100,000) is higher than the sum of all
new cancer diagnoses (all ages/types): 650 per 100,000 (95% confidence interval, 370.1Y371.7), yet the public health implica-
tions remain largely unstudied. These data can be used to guide future research into improved access to care, resource allocation,
and quality improvement efforts. (J Trauma Acute Care Surg. 2014;77: 202Y208. Copyright * 2014 by Lippincott Williams & Wilkins)
LEVEL OF EVIDENCE: Epidemiologic study, level III.
KEY WORDS: Acute care surgery; emergency general surgery; epidemiology; public health.

I n 2006, the Institute of Medicine described emergency care

as being at the ‘‘breaking point’’ in the United States; the
demand for emergency care continues to grow, while avail-
ability and access decline.1 Most recent data document nearly
130 million emergency department (ED) visits per year, with
projections to increase annually.2,3 However, rising health care
costs, the declining physician workforce,4 and an alarming
surge in ED closures3 threaten access and combine to create a
true public health crisis.
Surgeons provide emergency care in two settings: trauma
(intentional and unintentional injury) and nontrauma surgical
Submitted: April 14, 2014, Revised: May 6, 2014, Accepted: May 6, 2014.
From the Department of Surgery (S.C.G.), Division of Trauma Services, East Texas
Medical Center, Tyler, Texas; Department of Surgery (S.C.G., V.Y.D., D.A.,
J.S.C.), Rutgers-Robert Wood Johnson Medical School, New Brunswick, New
Jersey; and Baylor Institute for Health Care Research and Improvement (S.S.),
Dallas, Texas.
This study was presented as a poster at the 27th Annual Scientific Assembly of the
Eastern Association for the Surgery of Trauma, January 14Y18, 2014, in Naples,
Florida.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text, and links to the digital files are provided in the HTML text of
this article on the journal’s Web site (www.jtrauma.com).
Address for reprints: Stephen C. Gale, MD, Department of Surgery, Division of
Trauma Services, East Texas Medical Center, 1020 E. Idel St, Tyler, TX 75701;
email: scgale@etmc.org.
DOI: 10.1097/TA.0000000000000362
202
emergencies. Trauma care is well characterized and well studied
after four decades of national trauma system development.5 In
contrast, the ‘‘burden of disease’’ for nontrauma surgical emer-
gencies is unknown. Further, these illnesses are difficult to group
into a single ‘‘emergency general surgery’’ (EGS) entity, for
study or for treatment standardization, because of the vastly
greater number of hospitals providing EGS care and the an-
atomic and physiologic diversity of the myriad infectious,
obstructive, and hemorrhagic emergencies composing EGS.
Typically, surgical emergencies are treated by whomever
surgeon may be ‘‘on call’’Vwith call assigned, compulsory, and
independent of whether that surgeon is immediately available or
has the time, resources, or expertise to deliver appropriate care.6,7
The current system results in delays in care,8 significant practice
variation,9 and, at times, suboptimal outcomes.10 Indeed, mor-
bidity and mortality for emergency surgery are much greater than
after elective surgery,10,11 and the absence of collective EGS
investigation prevents separating the impact of suboptimal care
from complex physiology as contributors to poor outcomes.
Further, surgeon shortages, increased subspecialization, lifestyle
demands, and reimbursement pressures have caused fewer sur-
geons to elect to provide emergency coverage.4,12Y14
While the development of the acute care surgery (ACS)
specialist15,16 has helped identify and close some of these gaps
in care delivery in certain centers,8,17,18 the true national
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J Trauma Acute Care Surg
Volume 77, Number 2
burden of disease for EGS is unknown. Further, because most
of the surgical literature describes elective processes, large-
scale analyses of EGS outcomes are lacking19 and reports re-
lated to ACS have focused largely on individual diseases8,20,21
or process-of-care improvements.22
However, through the efforts of the American Association
for the Surgery of Trauma (AAST) and its affiliated organiza-
tions, the scientific and clinical approaches to EGS conditions
have evolved. An ACS fellowship-training paradigm was created
to prepare ‘‘trauma surgeons’’ for all manner of surgical emer-
gencies, rather than focusing on postinjury care; 14 programs
have been approved in the United States to date. Further, the
AAST has recently defined emergency general surgery, open-
ing the door to more comprehensive study and greater care
standardization.23
As ACS evolves, calls have begun for both EGS ‘‘re-
gionalization’’24 and the creation of quality assurance pro-
grams.25 For the first time, EGS is being seen less as a local
issue and more as a public health concern worthy of ‘‘organized
efforts and informed choices of society.26’’ In this light, de-
fining the ‘‘burden’’ of disease allows clinicians, institutions,
and communities to better assess and adjust resource alloca-
tion, devise best practice guidelines and performance im-
provement measures, and initiate multi-institutional research.25
Similar to the evolution of trauma care three decades ago, sur-
geons believe that this initiative will lead to improvements in
timeliness and quality of care and introduce performance im-
provement and accountability into this often-overlooked area of
surgical illness.25
In the present study, on the basis of the newly developed
AAST definition of EGS, we sought to describe the burden of
disease for emergent surgical diseases in the United States.
We believe that EGS patients represent a very large, diverse,
and physiologically challenging cohort and that the burden of
disease for EGS is increasing. Our aim was to describe the EGS
burden of disease and its evolution in the United States during
a 10-year period from 2001 to 2010.
PATIENTS AND METHODS
EGS Definition and Study Population
The Nationwide Inpatient Sample (NIS) from 2001 to
2010 was used for analysis. It is maintained by the Agency for
Healthcare Research and Quality and was developed as part of
the Healthcare Cost and Utilization Project.27 Sampled from
State Inpatient Databases, the NIS is the largest all-payer hospital
database in the United States, containing discharge data from
more than 1,000 hospitals representing more than 8 million ac-
tual hospitalizations. The NIS provides a 20% statistically robust
representative cross section of US hospital discharges and the
opportunity, using weighted calculations, to derive national es-
timates representing 40 million hospital discharges annually.
The study population was selected using the following
inclusion criteria:
1. Eighteen years or older
2. Admission type was emergent or urgent or from the ED
3. EGS disease as a principal diagnosis
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Gale et al.
Recently, the AAST compiled an initial list of DRG
International Classification of DiseasesV9th Rev.VClinical
Modification (ICD-9-CM) codes to represent and define EGS
disease.23 In all, 309 ICD-9-CM codes were identified (Sup-
plemental Table 1, http://links.lww.com/TA/A425). We used
these codes for Selection Criterion 3. To identify surgical
procedures performed during admissions, an exhaustive review
of ICD-9-CM procedure codes (00.0Y99.99) was undertaken.
We identified procedure codes that would or could apply to the
EGS-defining ICD-9-CM diagnoses (Supplemental Table 2,
http://links.lww.com/TA/A426).
Patients with sepsis as a complication were recognized with
these ICD-9-CM diagnosis codes in secondary positions: 038.xx,
112.5, 995.91, 995.92, and 785.52. We also used ICD-9-CM
diagnosis codes for secondary diagnoses specifying acute organ
dysfunction: 785.5x (shock [nontrauma]), 427.5 (cardiac arrest),
458 (hypotension: 458.0, 458.8, 458.9), 796.3 (nonspecific hy-
potension), 518.81 (acute respiratory failure), 518.82 (other pul-
monary insufficiency), 786.09 (respiratory distress/insufficiency),
799.1 (respiratory arrest), 348.31 (septic encephalopathy), 293.0
(acute delirium), 348.1 (anoxic brain damage), 780.01 (coma),
287.4 (secondary thrombocytopenia), 287.5 (thrombocytopenia,
unspecified), 286.6 (defibrination syndrome), 286.9 (unspecified
coagulation defects), 570 (acute/subacute necrosis of the liver),
572.2 (hepatic coma), 573.4 (hepatic infarction), and 584.x (acute
renal failure).
The study population was further classified into ‘‘cate-
gories’’ based on diagnosis type. Eleven categories were used
as follows: hepatopancreaticobiliary, colorectal, upper gastro-
intestinal tract (including the appendix), intestinal obstruc-
tion, hernia, general abdominal conditions, soft tissue, vascular,
cardiothoracic, resuscitation, and ‘‘others’’ (Supplement 1,
http://links.lww.com/TA/A425). Analysis by category included
overall admissions, operative rate, mortality, and sepsis data.
For comparison with the EGS burden, we queried avail-
able published reports for other common public health concerns.
For diabetes mellitus28 and human immunodeficiency virus,29
we used data from the Centers for Disease Control and Pre-
vention. For cancer, we reported data from the American Cancer
Society.30 For coronary artery disease, heart failure, and stroke,
we obtained data from the American Heart Association.31 These
data were expressed as annual incidence per 100,000 persons
with confidence intervals (CIs).
Statistical Analysis
Data analysis and statistics were performed with the SAS
9.2 software (SAS Institute, Cary, NC). Difference between two
groups was tested with the W2 analysis for categorical variables
and the t test for continuous variables. Linear regression analysis
and the Cochran-Armitage trend test were used to evaluate time
trends in the examined parameters. A value of p G 0.05 was
considered significant.
RESULTS
Burden of Emergent Surgical Disease
During the 10-year study period, there were an estimated
388,358,479 hospital admissions in the United States. Of these,
27,668,807 patients (7.12%) were admitted for EGS diagnoses
203
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Gale et al. Volume 77, Number 2

Figure 1. (A), Annual burden of disease for EGS: hospital admissions per year and percentage of total US admissions for that year. (B),
Surgical burden of disease for EGS: number of EGS admissions with surgical intervention during the same admission and annual
percentage of EGS admissions requiring surgery.

as defined. From 2001 to 2010, both the actual number of EGS
admissions and the proportion of admissions attributed to
EGS diagnoses increased steadily. In addition, the proportion
of EGS patients requiring surgery during their admission in-
creased from 659,340 (27.7%) in 2001 to 872,332 (28.7%) in
2010 ( p G 0.0001).
Figure 1A demonstrates the trend in EGS admissions dur-
ing the study period. The annual number of EGS admissions
increased from 2,380,535 in 2001 to 3,034,878 in 2010 ( p G 0.0001).
For 2010, this represents a nationwide rate of 1,290.3 (95% CI,
1,288.9Y1,291.8) per 100,000 people. Surgical volume and rates
(Fig. 1B) also increased annually from 659,340 in 2001 to
872,332 in 2010 ( p G 0.0001), translating to a 2010 surgical rate
of 370.9 (95% CI, 370.1Y371.7) per 100,000 people (annual
data in Supplemental Table 3, http://links.lww.com/TA/A427).
Figure 2 compares the single-year population-based rates
of EGS admissions and surgery with those of certain other no-
table public health concerns. The population-based EGS burden
was significantly higher than several other common public
health problems. The 2010 US rate of new diabetes mellitus

Figure 2. Incidence of admission for EGS conditions compared with other common public health concerns.

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J Trauma Acute Care Surg
Volume 77, Number 2 Gale et al.

Figure 3. Comparison of 10-year trends in EGS mortality and sepsis rates.

diagnoses (all ages/types) was 899.4 (95% CI, 898.2Y900.7),28 soft tissue, resuscitation, and others) comprised more than 20%
while the incidence of a new cancer diagnosis (all ages/types) of EGS admissions (Table 2).
was 650.3 (95% CI, 649.3Y651.3).30 EGS admissions were
three times higher than all heart failure admissions (470.3 EGS Insurance Rates and Hospital Data
[95% CI, 416.6Y418.2])31 and all new strokes (417.4 [95% CI,
In 2001, only 7% of the patients were uninsured for
416.6Y418.2])31 from 2009. EGS admission was more than
their EGS admission, which increased steadily to 10% by
60 times greater than new human immunodeficiency virus di-
2010 ( p G 0.0001). Similarly, rates for Medicaid increased from
agnoses (19.7 [95% CI, 19.5Y19.9])29 in 2010.
9.0% to 12.1% ( p G 0.0001). Conversely, private insurance
The demographics of the study population and the in-
coverage decreased from 34.6% to 29.9% ( p G 0.0001), while
cidence of common comorbidities are summarized in Table 1.
rates for Medicare decreased from 46.9% to 44.4% ( p G 0.0001)
The mean age was 58.7 years, and 35% of the patients were
70 years or older. More than 50% of the study population had
at least one chronic comorbid condition. Hypertension was the TABLE 1. Demographics of the Study Population
most common (43%); 20% of the patients were diabetic.
During the study period, 583,154 EGS patients (2.11%) Parameter n %
presented with or developed sepsis; of those, 325,746 (56%) Age, mean (SD), y 58.7 (19.9)
met criteria for severe sepsis. Sepsis rates increased signifi- 18Y29 2,478,331 8.96
cantly during the study period from 1.90% to 2.19% ( p G 0.0001) 30Y29 2,941,165 10.63
(Fig. 3). The proportion of septic patients with severe sepsis 40Y49 4,095,646 14.80
also increased from 49% to 64% ( p G 0.0001). 50Y59 4,432,702 16.02
60Y69 4,058,083 14.67
70Y79 4,550,506 16.45
EGS Mortality Q80 5,112,373 18.47
During the study period, 586,496 EGS patients (2.12%) Sex
died during their admission. Despite increasing EGS admissions, Male 12,598,564 45.62
hospital mortality steadily declined over time, from 2.73% in Female 15,020,370 54.38
2001 to 1.61% in 2010 ( p G 0.0001). This decline occurred Race
despite increasing sepsis rates (Fig. 3). White 15,306,011 71.44
Black 2,712,828 12.66
Hispanic 2,310,849 10.79
EGS Diagnosis Groups
Other 1,094,287 5.11
Hepatopancreaticobiliary conditions were the most com-
Comorbidities
mon EGS diseases (26%). This group also had a high operative
Hypertension 11,874,673 43.38
rate (40%) but a low sepsis rate (2%). Colorectal conditions were
Diabetes without chronic complications 4,714,407 17.22
the next most common but carried relatively low emergent
Chronic pulmonary disease 4,303,570 15.73
operative rates (16.5%). Hernia requiring admission had the
Congestive heart failure 2,478,036 9.05
highest operative rates (73%). Admissions for vascular condi-
Obesity 2,136,533 7.80
tions, while small in number, were complicated (sepsis, 6.5%,
Renal failure 1,801,550 6.58
and mortality, 13.0%). The resuscitation category was the smallest
Diabetes with chronic complications 902,047 3.30
but had the highest mortality (40.2%) and the highest sepsis rate.
Pulmonary circulation disease 304,215 1.11
Of note, nongastrointestinal conditions (vascular, cardiothoracic,

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 J Trauma Acute Care Surg
Gale et al. Volume 77, Number 2

Figure 4. Ten-year trends in health care insurance coverage: traditional coverage (private insurance and Medicare) compared with
underinsured (Medicaid and uninsured).

during the study period. For the combined 10-year period, 56% and its focus on emergent admission type, our 10-year exami-
of all EGS patients (15,344,148) were covered by public insur- nation of the same database also includes ‘‘urgent’’ admissions
ance (Medicare/Medicaid). and allows for a more comprehensive estimate of EGS burden
During the study period, the EGS patients were most and its public health implications. That EGS admissions are in-
commonly (84.5%) and increasingly treated at urban hospitals creasing is consistent with nationwide trends of ED use across
( p G 0.0001). While nonteaching hospitals cared for most of the country,2,3 and the elderly status of most patients is not
the EGS patients (60.33%), the proportion of patients treated surprising. The significant mortality reduction noted during the
at teaching hospitals increased from 37.5% to 41.8% during study period is certainly multifactorial but interestingly is most
the study period ( p G 0.0001). The mean length of stay during profound after the first release of the Surviving Sepsis Campaign
the study period decreased from 5.34 days in 2001 to 4.90 days guidelines in 2004.34
in 2010 ( p G 0.0001). While seemingly small, a reduction of Importantly, these are only index hospitalization data and
0.44 days in length of stay, multiplied by the 3,034,878 admis- therefore are likely a significant underestimation of the true
sions in 2010, may have reduced hospital charges by $2.5 billion burden of disease. Not represented is the additional burden of care
to $5.3 billion for that year based on the published range of daily for delayed surgical interventions undertaken ‘‘semielectively’’
hospital charges: $1,853 per day32 to $3,949 per day33 (Fig. 4). after an initial period of nonoperative management such as
colectomy for diverticular disease, interval appendectomy, de-
layed cholecystectomy, and others. Also not captured are sub-
DISCUSSION sequent surgeries required as a result of the first emergent
In the present study, we demonstrate, for the first time, procedure: colostomy reversal, ventral hernia repair, skin
that the burden of EGS conditions, affecting more than 1,290 of
100,000 persons per year, far exceeds that of many common, TABLE 2. Breakdown of EGS Admissions by Diagnosis
highly publicized and studied public health problems such as Category
new-onset diabetes mellitus (899 of 1,000,000 persons per year)
EGS Burden of Disease by Category: United States 2001Y2010
and newly diagnosed cancers (650 of 1,000,000 persons per year).
We also demonstrate that more than 3 million patients are ad- Operative Sepsis
Category Admissions % Rate Rate Mortality
mitted annually to US hospitals emergently or urgently with EGS
conditions and that more than a quarter of them require surgery Hepatopancreaticobiliary 7,116,823 25.7 40.1% 2.0% 1.6%
during that admission. These are complex patients, with half Colorectal 5,207,193 18.8 16.5% 2.2% 2.2%
older than 60 years, and most have comorbidities. While sepsis Upper 4,626,204 16.7 31.1% 2.1% 2.0%
rates have remained relatively stable during the study period, we gastrointestinal tract
document a 40% reduction in mortality (2.73Y1.61%) for EGS Soft tissue 4,494,498 16.3 26.2% 1.6% 0.7%
conditions from 2001 to 2010. We also document that while Intestinal obstruction 3,877,574 14.0 11.4% 1.6% 1.9%
emergent admissions and surgeries increased, reimbursement Hernia 912,249 3.3 72.6% 2.2% 2.0%
for this care may be declining, as EGS patients are increasingly Vascular 683,280 2.5 28.8% 6.5% 13.0%
uninsured or underinsured. Cardiothoracic 511,739 1.8 60.2% 4.1% 4.7%
Our data support and extend the findings of Shafi et al.23 General abdominal 188,223 0.7 22.8% 4.3% 3.7%
conditions
from the AAST Acute Care Surgery Committee, who first
Others 29,472 0.1 5.5% 5.9% 5.1%
compiled the ICD-9 codes that define EGS and described the
Resuscitation 21,552 0.1 4.4% 13.3% 40.2%
burden of ‘‘emergent’’ admissions for a single year (2009) using
Totals 27,668,807 28.8% 2.1% 2.1%
the NIS. While that study was limited by its single-year analysis

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J Trauma Acute Care Surg
Volume 77, Number 2
grafting, serial wound debridements, and others. Finally, patients
seen in the ED by surgeons, who are not admitted to the hospital
but rather are discharged from the ED to be followed as out-
patients, are also not included, that is, patients with perirectal
abscess, nonincarcerated hernia, and biliary colic.
During the study period, we document a progressive
change in payer mix for EGS patients. Health care coverage for
the uninsured or the underinsured has been the source of sig-
nificant political debate and was a major impetus to the Patient
Protection and Affordable Care Act signed into law in 2010.35
It is not known how these financial trends will impact the
growth of ACS, as EGS is incorporated, but a report by Shafi
et al.36 indicates that urban trauma centers will be negatively
impacted by the expansion of Medicare-type rolls (a major
component of the Patient Protection and Affordable Care Act).
While EGS care and trauma care are certainly very different, in
that our data demonstrate that most patients with EGS condi-
tions are treated in urban centers, and increasingly in academic
centers, Medicaid expansion may have a similar impact on EGS
care reimbursement.
Our documentation of an ever-increasing EGS volume,
coupled with potential financial pressures, may accelerate an
already apparent public health crisis: too few surgeons to meet
the need.4 In the United States, the number of surgeons prac-
ticing annually has remained unchanged, while the population
continues to increase.14 Lynge37 documented a 25.91% decrease
in practicing general surgeons per a population of 100,000 from
1981 to 2005, and Williams et al.12 project a 9.2% decrease in
general surgeons per capita from 2010 to 2030. Further, in-
creased surgeon specialization,7,38 reduced willingness to par-
ticipate in an emergency call, early retirement, and declining
reimbursement have combined to create a crisis in the delivery of
emergency surgical care across the country.4,39 While the fusion
of EGS with trauma care to create ‘‘acute care surgery’’ will
likely stave off the crisis for some larger centers,15,40 many
questions remain regarding ACS implementation in general41
and its ability to improve emergency surgical care in rural and
underserved areas specifically. Should EGS regionalization
become widespread,24 like trauma care before it, the present
study will be critical to predict resource needs and guide allo-
cation, to implement and monitor quality improvement initiatives
and to ensure ACS sustainability. Future expansion of this work
should include the creation of a standardized EGS classification
and scoring system to further clarify the EGS burden and to
facilitate outcomes research. Together, this and future studies
will emphasize the need to strengthen and expand the ACS
training paradigm at both the residency and fellowship levels; our
data exposing the enormous burden of EGS make clear
the vital role that ACS programs will serve in the future of
emergency health care delivery.
Limitations
The present study has several limitations, the most re-
lated to its data source. While the NIS is a large and useful
database, it is administrative in nature, containing only limited
clinical data, and, as a ‘‘sample,’’ it yields only estimates of ad-
missions rather than actual numbers. Without physiologic
data within the NIS, no mortality risk assessments or attempt
at severity of disease grading for admissions can be made.
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Gale et al.
Importantly, no data are available for the type of physician
or surgeon caring for patients, precluding any assessment
of decision making for surgery, delays to source control, or other
factors contributing to outcomes. With the NIS, data do not in-
clude Veteran’s Administration and other federal facilities, and
data reporting for certain elements may vary by state, sources of
underestimation of EGS burden. Coding errors or modifications
to diagnosis or procedure codes may have occurred, which could
yield inaccurate conclusions. For our study aim, these limitations
are offset by the large number of patients the NIS contains and the
ability to enable trend analysis for long periods. Importantly, the
NIS has been benchmarked for quality with other common ad-
ministrative databases and has been proven accurate for reliable
analysis. Its relative ease of analysis and cost-effectiveness also
contribute to making the NIS, despite its inherent limitations,
ideal for this initial, large-scale burden of disease assessment.
CONCLUSION
EGS conditions represent a very large and complex patient
population that is growing annually. In the present study, we
explore, for the first time, the public health implications of this
massive disease burden and suggest that a crisis is at hand: a
growing need for emergency surgical care at a time of progres-
sively declining surgeon availability. While large, urban centers
are best equipped to care for many of these complex patients and
may serve as foci for regionalization, the sheer volume of patients
requiring treatment for EGS conditions may prove prohibitive.
Future efforts, using this and other data, must be directed not only
at studying processes of care and quality improvement but also at
ensuring adequate organizational planning and proper resource
allocation for the growth of ACS programs in an evolving health
care environment.
AUTHORSHIP
S.C.G., D.A., and S.S. designed this study. S.C.G. and D.A. conducted
the literature search. V.Y.D. contributed to data collection. S.C.G. per-
formed data analysis. S.C.G., S.S., V.Y.D., and J.S.C. interpreted the
data. S.C.G. wrote the manuscript and, with J.S.C., prepared figures. All
authors participated in critical revision. S.C.G. and V.Y.D. had full access
to all data in the study and take responsibility for the integrity of the
data and the accuracy of the data analysis.
ACKNOWLEDGMENT
We thank Vicente Gracias, MD, for his contribution to early study design.
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