Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea4Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.
JAMA Surg. 2014 Jul;149(7):633-40. doi: 10.1001/jamasurg.2014.241.
The number of geriatric patients who undergo surgery has been increasing, but there are insufficient tools to predict postoperative outcomes in the elderly.
To design a predictive model for adverse outcomes in older surgical patients.
DESIGN, SETTING, AND PARTICIPANTS: From October 19, 2011, to July 31, 2012, a single tertiary care center enrolled 275 consecutive elderly patients (aged ≥65 years) undergoing intermediate-risk or high-risk elective operations in the Department of Surgery.
The primary outcome was the 1-year all-cause mortality rate. The secondary outcomes were postoperative complications (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission), length of hospital stay, and discharge to nursing facility.
Twenty-five patients (9.1%) died during the follow-up period (median [interquartile range], 13.3 [11.5-16.1] months), including 4 in-hospital deaths after surgery. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Malignant disease and low serum albumin levels were more common in the patients who died. Among the geriatric assessment domains, Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition were associated with increased mortality rates. A multidimensional frailty score model composed of the above items predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification (area under the receiver operating characteristic curve, 0.821 vs 0.647; P = .01). The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model's cutoff point (>5 vs ≤5). High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = .003) and longer hospital stays after surgery (median [interquartile range], 9 [5-15] vs 6 [3-9] days; P < .001).
The multidimensional frailty score based on comprehensive geriatric assessment is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery.
接受手术的老年患者人数不断增加，但缺乏预测老年患者术后结果的工具。
设计一种预测老年外科患者不良结局的模型。
设计、地点和参与者：2011 年 10 月 19 日至 2012 年 7 月 31 日，一家单一的三级护理中心从外科部门招募了 275 名连续接受中危或高危择期手术的老年患者（年龄≥65 岁）。
主要结果是 1 年全因死亡率。次要结果是术后并发症（如肺炎、尿路感染、谵妄、急性肺血栓栓塞和非计划性重症监护病房入院）、住院时间和出院到护理机构。
在随访期间，有 25 名患者（9.1%）死亡（中位数[四分位距]，13.3[11.5-16.1]个月），其中 4 名在手术后院内死亡。29 名患者（10.5%）术后至少发生 1 种并发症，24 名（8.7%）出院至护理机构。死亡患者中恶性疾病和低血清白蛋白水平更为常见。在老年评估领域中，Charlson 合并症指数、日常生活活动依赖、工具性日常生活活动依赖、痴呆、谵妄风险、中臂周长短和营养不良与死亡率增加相关。由上述项目组成的多维虚弱评分模型比美国麻醉医师协会分类（接受者操作特征曲线下面积，0.821 与 0.647；P = .01）更能准确预测全因死亡率。根据该模型的截断值（>5 与≤5），预测全因死亡率的敏感性和特异性分别为 84.0%和 69.2%。高危患者（多维虚弱评分>5）术后死亡率风险增加（风险比，9.01；95%CI，2.15-37.78；P = .003），术后住院时间延长（中位数[四分位距]，9[5-15]与 6[3-9]天；P < .001）。
基于全面老年评估的多维虚弱评分比传统方法更能预测接受手术的老年患者的结局。
