溃疡性结肠炎中药物治疗与择期结肠切除术相关的死亡率：一项队列研究。
Mortality associated with medical therapy versus elective colectomy in ulcerative colitis: a cohort study.
作者信息
Bewtra Meenakshi, Newcomb Craig W, Wu Qufei, Chen Lang, Xie Fenglong, Roy Jason A, Aarons Cary B, Osterman Mark T, Forde Kimberly A, Curtis Jeffrey R, Lewis James D
出版信息
Ann Intern Med. 2015 Aug 18;163(4):262-70. doi: 10.7326/M14-0960.
BACKGROUND
Ulcerative colitis (UC) can be treated with surgery or medications. Patients often must choose between long-term immunosuppressant therapy or total colectomy. Whether one of these treatment approaches has a mortality benefit is uncertain.
OBJECTIVE
To determine whether patients with advanced UC treated with elective colectomy have improved survival compared with those treated with medical therapy.
DESIGN
Retrospective matched cohort study.
SETTING
Data from all 50 states for Medicaid beneficiaries (2000 to 2005), Medicare beneficiaries (2006 to 2011), and dual-eligible persons (2000 to 2011).
PATIENTS
830 patients with UC pursuing elective colectomy and 7541 matched patients with UC pursuing medical therapy.
MEASUREMENTS
The primary outcome was time to death. Cox proportional hazards models were used to compare the survival of patients with advanced UC treated with elective colectomy or medical therapy. The models controlled for significant comorbid conditions through matched and adjusted analysis.
RESULTS
The mortality rates associated with elective surgery and medical therapy were 34 and 54 deaths per 1000 person-years, respectively. Elective colectomy was associated with improved survival compared with long-term medical therapy (adjusted hazard ratio [HR], 0.67 [95% CI, 0.52 to 0.87]), although this result did not remain statistically significant in all sensitivity analyses. Post hoc analysis by age group showed improved survival with surgery in patients aged 50 years or older with advanced UC (HR, 0.60 [CI, 0.45 to 0.79]; P = 0.032 for age-by-treatment interaction).
LIMITATIONS
Retrospective nonrandomized analysis is subject to residual confounding. The source cohort was derived from different databases throughout the study. Sensitivity and secondary analyses had reduced statistical power.
CONCLUSION
Elective colectomy seemed to be associated with improved survival relative to medical therapy among patients aged 50 years or older with advanced UC.
PRIMARY FUNDING SOURCE
National Institutes of Health and Agency for Healthcare Research and Quality.
背景
溃疡性结肠炎（UC）可通过手术或药物治疗。患者常常必须在长期免疫抑制治疗或全结肠切除术之间做出选择。这两种治疗方法是否具有死亡率益处尚不确定。
目的
确定与接受药物治疗的晚期UC患者相比，接受择期结肠切除术的患者生存率是否有所提高。
设计
回顾性匹配队列研究。
地点
来自所有50个州的医疗补助受益人（2000年至2005年）、医疗保险受益人（2006年至2011年）和双重资格人员（2000年至2011年）的数据。
患者
830例接受择期结肠切除术的UC患者和7541例匹配的接受药物治疗的UC患者。
测量指标
主要结局为死亡时间。采用Cox比例风险模型比较接受择期结肠切除术或药物治疗的晚期UC患者的生存率。模型通过匹配和调整分析控制显著的合并症。
结果
与择期手术和药物治疗相关的死亡率分别为每1000人年34例和54例死亡。与长期药物治疗相比，择期结肠切除术与生存率提高相关（调整后风险比[HR]，0.67[95%CI，0.52至0.87]），尽管在所有敏感性分析中该结果并非均保持统计学显著性。按年龄组进行的事后分析显示，50岁及以上晚期UC患者手术可提高生存率（HR，0.60[CI，0.45至0.79]；年龄与治疗交互作用的P=0.032）。
局限性
回顾性非随机分析存在残余混杂因素。整个研究中的源队列来自不同的数据库。敏感性和二次分析的统计效力降低。
结论
对于50岁及以上的晚期UC患者，择期结肠切除术似乎比药物治疗能提高生存率。
主要资金来源
美国国立卫生研究院和医疗保健研究与质量局。
Zotero 插件