Weissler Jason M, Lanni Michael A, Hsu Jesse Y, Tecce Michael G, Carney Martin J, Kelz Rachel R, Fox Justin P, Fischer John P
Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
J Am Coll Surg. 2017 Aug;225(2):274-284.e1. doi: 10.1016/j.jamcollsurg.2017.04.007. Epub 2017 Apr 23.
Incisional hernia remains a persistent and burdensome complication after colectomy. Through individualized risk-assessment and prediction models, we aimed to improve preoperative risk counseling for patients undergoing colectomy; identify modifiable preoperative risk factors; and encourage the use of evidence-based risk-prediction instruments in the clinical setting.
A retrospective review of the Healthcare Cost and Utilization Project data was conducted for all patients undergoing either open or laparoscopic colectomy as identified through the state inpatient databases of California, Florida, and New York in 2009. Incidence of incisional hernia repair was collected from both the state inpatient databases and the state ambulatory surgery and services databases in the 3 states between index surgery and 2011. Hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrapping techniques. Exclusion criteria included concurrent hernia, metastasis, mortality, and age younger than 18 years. Inflation-adjusted expenditure estimates were calculated.
Overall, 30,741 patients underwent colectomy, one-third of these procedures performed laparoscopically. Incisional hernia repair was performed in 2,563 patients (8.3%) (27-month follow-up). Fourteen significant risk factors were identified, including open surgery (odds ratio = 1.49; p < 0.0001), obesity (odds ratio = 1.49; p < 0.0001), and alcohol abuse (odds ratio = 1.39; p = 0.010). Extreme-risk patients experienced the highest incidence of incisional hernia (19.8%) vs low-risk patients (3.9%) (C-statistic = 0.67).
We present a clinically actionable model of incisional hernia using all-payer claims after colectomy. The data presented can structure preoperative risk counseling, identify modifiable patient-specific risk factors, and advance the field of risk prediction using claims data.
切口疝仍是结肠切除术后持续存在且负担沉重的并发症。通过个体化风险评估和预测模型，我们旨在改善接受结肠切除术患者的术前风险咨询；识别可改变的术前风险因素；并鼓励在临床环境中使用基于证据的风险预测工具。
对2009年通过加利福尼亚州、佛罗里达州和纽约州住院患者数据库确定的所有接受开放或腹腔镜结肠切除术的患者进行医疗保健成本和利用项目数据的回顾性分析。从这三个州的住院患者数据库以及门诊手术和服务数据库中收集索引手术至2011年期间切口疝修复的发生率。采用多变量分层逻辑回归模型计算疝风险，并使用自抽样技术进行验证。排除标准包括并发疝、转移、死亡以及年龄小于18岁。计算了经通胀调整的支出估计值。
总体而言，30741例患者接受了结肠切除术，其中三分之一的手术为腹腔镜手术。2563例患者（8.3%）进行了切口疝修复（27个月随访）。确定了14个显著风险因素，包括开放手术（比值比 = 1.49；p < 0.0001）、肥胖（比值比 = 1.49；p < 0.0001）和酒精滥用（比值比 = 1.39；p = 0.010）。极高风险患者的切口疝发生率最高（19.8%），而低风险患者为3.9%（C统计量 = 0.67）。
我们使用结肠切除术后的全付费者索赔数据提出了一种临床可行的切口疝模型。所呈现的数据可为术前风险咨询提供框架，识别特定患者可改变的风险因素，并推动使用索赔数据进行风险预测的领域发展。
