Wijeysundera Duminda N, Austin Peter C, Beattie W Scott, Hux Janet E, Laupacis Andreas
Institute for Clinical Evaluative Sciences, Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada.
Arch Intern Med. 2010 Aug 9;170(15):1365-74. doi: 10.1001/archinternmed.2010.204.
Preoperative consultations by internal medicine physicians facilitate documentation of comorbid disease, optimization of medical conditions, risk stratification, and initiation of interventions intended to reduce risk. Nonetheless, the impact of these consultations, which may be performed by general internists or specialists, on outcomes is unclear.
We used population-based administrative databases to conduct a cohort study of patients 40 years or older who underwent major elective noncardiac surgery in Ontario, Canada, between 1994 and 2004. Propensity scores were used to assemble a matched-pairs cohort that reduced differences between patients who did and did not undergo preoperative consultation by general internists or specialists. The association of consultation with mortality and hospital stay was determined within this matched cohort. As a sensitivity analysis, we evaluated the association of consultation with an outcome for which no difference would be expected: postoperative wound infection.
Of 269,866 patients in the cohort, 38.8% (n=104,695) underwent consultation. Within the matched cohort (n=191,852), consultation was associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year mortality (1.08; 1.04-1.12; number needed to harm, 227), mean hospital stay (difference, 0.67 days; 0.59-0.76), preoperative testing, and preoperative pharmacologic interventions. Notably, consultation was not associated with any difference in postoperative wound infections (RR, 0.98; 95% CI, 0.95-1.02). These findings were stable across subgroups as well as sensitivity analyses that tested for unmeasured confounding.
Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing. These findings highlight the need to better understand mechanisms by which consultation influences outcomes and to identify efficacious interventions to decrease perioperative risk.
内科医生进行术前会诊有助于记录合并症、优化医疗状况、进行风险分层以及启动旨在降低风险的干预措施。然而，这些可能由普通内科医生或专科医生进行的会诊对手术结果的影响尚不清楚。
我们利用基于人群的行政数据库，对1994年至2004年期间在加拿大安大略省接受重大择期非心脏手术的40岁及以上患者进行了一项队列研究。倾向评分用于组建一个匹配对列，以减少接受普通内科医生或专科医生术前会诊与未接受术前会诊患者之间的差异。在这个匹配队列中确定会诊与死亡率和住院时间的关联。作为敏感性分析，我们评估了会诊与预期无差异的结果之间的关联：术后伤口感染。
在队列中的269,866名患者中，38.8%（n = 104,695）接受了会诊。在匹配队列（n = 191,852）中，会诊与30天死亡率增加（相对风险[RR]，1.16；95%置信区间[CI]，1.07 - 1.25；伤害所需人数，516）、1年死亡率增加（1.08；1.04 - 1.12；伤害所需人数，227）、平均住院时间延长（差异，0.67天；0.59 - 0.76）、术前检查以及术前药物干预相关。值得注意的是，会诊与术后伤口感染的任何差异均无关联（RR，0.98；95% CI，0.95 - 1.02）。这些发现在各个亚组以及检测未测量混杂因素的敏感性分析中均保持稳定。
重大择期非心脏手术前的医学会诊与死亡率增加、住院时间延长以及术前药物干预和检查增加相关。这些发现凸显了有必要更好地理解会诊影响手术结果的机制，并确定有效的干预措施以降低围手术期风险。
