From the Johns Hopkins University School of Medicine (A.M.) and Department of Surgery (L.A.D., J.K.C., K.S., C.J., E.R.H., D.T.E., J.V.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Surgery (B.J.), College of Medicine, University of Arizona, Tucson, Arizona.
J Trauma Acute Care Surg. 2018 Jun;84(6):864-875. doi: 10.1097/TA.0000000000001829.
Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes.
We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters.
We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes.
Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients.
Prognostic and epidemiological, level IV.
接受急诊普通外科（EGS）治疗的老年患者面临着显著的发病率和死亡率。我们评估了外科医生和医院的工作量如何影响这些结果。
我们从马里兰州卫生服务成本审查委员会数据库中确定了 2012 年至 2014 年期间至少 65 岁的患者，这些患者接受了美国创伤外科学会定义的 12 种 EGS 手术之一，然后计算了四种结果：死亡率、至少八种常见的院内 EGS 并发症之一的发生率、未能抢救（经历术后并发症后死亡）和 30 天再入院率。每年进行的老年 EGS 手术中位数将外科医生和医院分为两组（低工作量和高工作量）。多变量逻辑回归在调整了患者、外科医生和医院因素以及医院集群后，计算了两组之间与结果的关联。
我们确定了 3832 名患者接受了 302 名外科医生（中位数：8 例老年 EGS/年，IQR：3-18）在 44 家医院（中位数：82 例老年 EGS/年，IQR：35-132）进行的 EGS 手术。尽管低工作量的外科医生仅对 16.5%的老年 EGS 患者进行了手术，但他们的风险调整后不良结果风险更高：死亡率（7.0%比 4.0%，p=0.005）、院内并发症（22.1%比 19.7%，p=0.13）、未能抢救（17.3%比 12.1%，p=0.021）和 30 天再入院率（11.2%比 10.0%，p=0.55）。经过调整后，低工作量的外科医生与更高的死亡率（调整后的优势比[aOR]1.86，95%置信区间[CI]为 1.21-2.86）和未能抢救的风险（aOR 1.74 [1.09-2.80]）相关，但与院内并发症（aOR 1.20 [0.95-1.51]）或 30 天再入院率（aOR 1.07 [0.85-1.34]）无关。相比之下，与高工作量的医院相比，低工作量的医院和为较少老年 EGS 患者提供服务的医院与不良结果无关。
与高工作量的外科医生相比，每年进行 8 次或更少老年 EGS 手术的外科医生在这一老年 EGS 患者人群中，死亡的几率增加了 86%，未能抢救的几率增加了 74%。这些发现强调了需要对老年手术患者进行有针对性的护理。
预后和流行病学，IV 级。
