From the Departments of Anesthesiology and Pain Medicine (D.I.M., G.L.B.) Internal Medicine (C.v.W.) the School of Epidemiology and Public Health (D.I.M., C.v.W.), University of Ottawa, Ottawa, Ontario, Canada the Departments of Anesthesiology and Pain Medicine (D.I.M., G.L.B.) Internal Medicine (C.v.W.) the Research Institute (D.I.M., G.L.B., C.v.W.), The Ottawa Hospital, Ottawa, Ontario, Canada the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.I.M., C.A.W., C.v.W.).
Anesthesiology. 2018 Jun;128(6):1140-1150. doi: 10.1097/ALN.0000000000002124.
Polypharmacy is increasingly prevalent in older patients and is associated with adverse events among medical patients. The impact of polypharmacy on outcomes after elective surgery is poorly described. The authors' objective was to measure the association of polypharmacy with survival, complications, and resource use among older patients undergoing elective surgery.
After registration (NCT03133182), the authors identified all individuals older than 65 yr old having their first elective noncardiac surgery in Ontario, Canada, between 2002 and 2014. Using linked administrative data, the authors identified all prescriptions dispensed in the 90 days before surgery and classified people receiving five or more unique medications with polypharmacy. The associations of polypharmacy with 90-day survival (primary outcome), complications, length of stay, costs, discharge location, and readmissions were estimated after multilevel, multivariable adjustment for demographics, comorbidities, previous healthcare use, and surgical factors. Prespecified and post hoc sensitivity analyses were also performed.
Of 266,499 patients identified, 146,026 (54.8%) had polypharmacy. Death within 90 days occurred in 4,356 (3.0%) patients with polypharmacy and 1,919 (1.6%) without (adjusted hazard ratio = 1.21; 95% CI, 1.14 to 1.27). Sensitivity analyses demonstrated no increase in effect when only high-risk medications were considered and attenuation of the effect when only prescriptions filled in the 30 preoperative days were considered (hazard ratio = 1.07). Associations were attenuated or not significant in patients with frailty and higher comorbidity scores.
Older patients with polypharmacy represent a high-risk stratum of the perioperative population. However, the authors' findings call into question the causality and generalizability of the polypharmacy-adverse outcome association that is well documented in nonsurgical patients.
在老年患者中，多种药物治疗越来越普遍，并且与医疗患者的不良事件有关。多种药物治疗对择期手术后结果的影响描述不足。作者的目的是衡量多种药物治疗与择期手术老年患者的生存率、并发症和资源利用之间的关系。
登记后（NCT03133182），作者确定了 2002 年至 2014 年间在加拿大安大略省进行首次择期非心脏手术的所有年龄在 65 岁以上的个体。作者使用链接的行政数据确定了手术前 90 天内开具的所有处方，并将接受五种或更多种独特药物的患者分类为多种药物治疗。在进行多层次、多变量调整以考虑人口统计学、合并症、先前的医疗保健使用和手术因素后，估计了多种药物治疗与 90 天生存率（主要结局）、并发症、住院时间、成本、出院地点和再入院之间的关系。还进行了预设和事后敏感性分析。
在确定的 266499 名患者中，146026 名（54.8%）患有多种药物治疗。有多种药物治疗的患者中，90 天内死亡的有 4356 例（3.0%），无多种药物治疗的患者中，1919 例（1.6%）（调整后的危险比=1.21；95%置信区间，1.14 至 1.27）。敏感性分析表明，仅考虑高危药物时，效果无增加，仅考虑术前 30 天内开具的处方时，效果减弱（危险比=1.07）。在脆弱和合并症评分较高的患者中，关联减弱或不显著。
患有多种药物治疗的老年患者代表围手术期人群中的高危人群。然而，作者的发现对在非手术患者中记录良好的多种药物治疗与不良结果之间的因果关系和普遍性提出了质疑。
