播散性恶性肿瘤术后患者住院时间延长、再入院率及转至护理机构出院率增加：对临床实践的启示
Increased Rates of Prolonged Length of Stay, Readmissions, and Discharge to Care Facilities among Postoperative Patients with Disseminated Malignancy: Implications for Clinical Practice.
作者信息
Bateni Sarah B, Meyers Frederick J, Bold Richard J, Canter Robert J
机构信息
Division of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California, United States of America.
Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California, United States of America.
出版信息
PLoS One. 2016 Oct 25;11(10):e0165315. doi: 10.1371/journal.pone.0165315. eCollection 2016.
BACKGROUND
The impact of surgery on end of life care for patients with disseminated malignancy (DMa) is incompletely characterized. The purpose of this study was to evaluate postoperative outcomes impacting quality of care among DMa patients, specifically prolonged length of hospital stay, readmission, and disposition.
METHODS
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for years 2011-2012. DMa patients were matched to non-DMa patients with comparable clinical characteristics and operation types. Primary hepatic operations were excluded, leaving a final cohort of 17,972 DMa patients. The primary outcomes were analyzed using multivariate Cox regression models.
RESULTS
DMa patients represented 2.1% of all ACS-NSQIP procedures during the study period. The most frequent operations were bowel resections (25.3%). Compared to non-DMa matched controls, DMa patients had higher rates of postoperative overall morbidity (24.4% vs. 18.7%, p<0.001), serious morbidity (14.9% vs. 12.0%, p<0.001), mortality (7.6% vs. 2.5%, p<0.001), prolonged length of stay (32.2% vs. 19.8%, p<0.001), readmission (15.7% vs. 9.6%, p<0.001), and discharges to facilities (16.2% vs. 12.9%, p<0.001). Subgroup analyses of patients by procedure type showed similar results. Importantly, DMa patients who did not experience any postoperative complication experienced significantly higher rates of prolonged length of stay (23.0% vs. 11.8%, p<0.001), readmissions (10.0% vs. 5.2%, p<0.001), discharges to a facility (13.2% vs. 9.5%, p<0.001), and 30-day mortality (4.7% vs. 0.8%, p<0.001) compared to matched non-DMa patients.
CONCLUSION
Surgical interventions among DMa patients are associated with poorer postoperative outcomes including greater postoperative complications, prolonged length of hospital stay, readmissions, disposition to facilities, and death compared to non-DMa patients. These data reinforce the importance of clarifying goals of care for DMa patients, especially when acute changes in health status potentially requiring surgery occur.
背景
手术对播散性恶性肿瘤（DMa）患者临终关怀的影响尚未完全明确。本研究旨在评估影响DMa患者护理质量的术后结局，特别是延长的住院时间、再入院率和出院去向。
方法
查询美国外科医师学会国家外科质量改进计划（ACS-NSQIP）2011 - 2012年的数据库。将DMa患者与具有可比临床特征和手术类型的非DMa患者进行匹配。排除原发性肝脏手术，最终队列有17972例DMa患者。使用多变量Cox回归模型分析主要结局。
结果
在研究期间，DMa患者占所有ACS-NSQIP手术的2.1%。最常见的手术是肠切除术（25.3%）。与匹配的非DMa对照组相比，DMa患者术后总体并发症发生率更高（24.4%对18.7%，p<0.001）、严重并发症发生率更高（14.9%对12.0%，p<0.001）、死亡率更高（7.6%对2.5%，p<0.001）、住院时间延长（32.2%对19.8%，p<0.001）、再入院率更高（15.7%对9.6%，p<0.001）以及转至其他机构的出院率更高（16.2%对12.9%，p<0.001）。按手术类型对患者进行亚组分析显示了类似结果。重要的是，与匹配的非DMa患者相比，未发生任何术后并发症的DMa患者在住院时间延长（23.0%对11.8%，p<0.001）、再入院率（10.0%对5.2%，p<0.001）、转至其他机构的出院率（13.2%对9.5%，p<0.001）和30天死亡率（4.7%对0.8%，p<0.001）方面的发生率显著更高。
conclusion：与非DMa患者相比，DMa患者的手术干预与较差的术后结局相关，包括更多的术后并发症、延长的住院时间、再入院率、转至其他机构的出院率和死亡。这些数据强化了明确DMa患者护理目标的重要性，尤其是当健康状况发生可能需要手术的急性变化时。
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