Schwarze Margaret L, Barnato Amber E, Rathouz Paul J, Zhao Qianqian, Neuman Heather B, Winslow Emily R, Kennedy Gregory D, Hu Yue-Yung, Dodgion Christopher M, Kwok Alvin C, Greenberg Caprice C
Department of Surgery, University of Wisconsin Hospital and Clinics, Madison.
Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
JAMA Surg. 2015 Apr;150(4):325-31. doi: 10.1001/jamasurg.2014.1819.
No consensus exists regarding the definition of high-risk surgery in older adults. An inclusive and precise definition of high-risk surgery may be useful for surgeons, patients, researchers, and hospitals.
To develop a list of high-risk operations.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study and modified Delphi procedure. The setting included all Pennsylvania acute care hospitals (Pennsylvania Health Care Cost Containment Council [PHC4] April 1, 2001, to December 31, 2007) and a nationally representative sample of US acute care hospitals (Nationwide Inpatient Sample [NIS], Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality January 1, 2001, to December 31, 2006). Patients included were those 65 years and older admitted to PHC4 hospitals and those 18 years and older admitted to NIS hospitals. We identified International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes associated with at least 1% inpatient mortality in the PHC4. We used a modified Delphi procedure with 5 board-certified surgeons to further refine this list by excluding nonoperative procedures and operations that were unlikely to be the proximate cause of mortality and were instead a marker of critical illness (eg, tracheostomy). We then cross-validated this list of ICD-9-CM codes in the NIS.
Modified Delphi procedure consensus of at least 4 of 5 panelists and proportion agreement in the NIS.
Among 4,739,522 admissions of patients 65 years and older in the PHC4, a total of 2,569,589 involved a procedure, encompassing 2853 unique procedures. Of 1130 procedures associated with a crude inpatient mortality of at least 1%, 264 achieved consensus as high-risk operations by the modified Delphi procedure. The observed inpatient mortality in the NIS was at least 1% for 227 of 264 procedures (86%) in patients 65 years and older. The pooled inpatient mortality for these identified high-risk procedures performed on patients 65 years and older was double the pooled inpatient mortality for correspondingly identified high-risk operations for patients younger than 65 years (6% vs 3%).
We developed a list of procedure codes to identify high-risk surgical procedures in claims data. This list of high-risk operations can be used to standardize the definition of high-risk surgery in quality and outcomes-based studies and to design targeted clinical interventions.
关于老年患者高风险手术的定义尚无共识。一个全面且精确的高风险手术定义对外科医生、患者、研究人员和医院可能会有所帮助。
制定一份高风险手术清单。
设计、背景和参与者：回顾性队列研究及改良德尔菲法。背景包括宾夕法尼亚州所有急性护理医院（宾夕法尼亚医疗成本控制委员会[PHC4]，2001年4月1日至2007年12月31日）以及美国急性护理医院的全国代表性样本（全国住院患者样本[NIS]，医疗保健成本与利用项目，医疗保健研究与质量局，2001年1月1日至2006年12月31日）。纳入的患者为65岁及以上入住PHC4医院的患者以及18岁及以上入住NIS医院的患者。我们确定了与PHC4中至少1%住院死亡率相关的国际疾病分类第九版临床修订本（ICD - 9 - CM）手术编码。我们采用改良德尔菲法，由5名获得委员会认证的外科医生进一步完善该清单，排除非手术操作以及不太可能是死亡直接原因而是严重疾病标志的手术（如气管切开术）。然后我们在NIS中对这份ICD - 9 - CM编码清单进行交叉验证。
5名小组成员中至少4人达成改良德尔菲法共识以及NIS中的比例一致性。
在PHC4中65岁及以上患者的4739522次入院中，共有2569589次涉及手术，涵盖2853种不同手术。在与至少1%的粗略住院死亡率相关的1130种手术中，264种通过改良德尔菲法达成高风险手术共识。在65岁及以上患者中，NIS中264种手术中的227种（86%）观察到的住院死亡率至少为1%。对65岁及以上患者进行的这些确定的高风险手术的合并住院死亡率是对65岁以下患者相应确定的高风险手术合并住院死亡率的两倍（6%对3%）。
我们制定了一份手术编码清单，以在索赔数据中识别高风险手术程序。这份高风险手术清单可用于在基于质量和结局的研究中规范高风险手术的定义，并设计有针对性的临床干预措施。
