Ha Albert, Krasnow Ross E, Mossanen Matthew, Nagle Ramzy, Hshieh Tammy T, Rudolph James L, Chang Steven L
Center for Surgery & Public Health and Division of Urology, Brigham and Women's Hospital, Boston, MA.
Department of Urology, MedStar Washington Hospital Center, Washington, DC.
Urol Oncol. 2018 Jul;36(7):341.e15-341.e22. doi: 10.1016/j.urolonc.2018.04.012. Epub 2018 May 24.
Postoperative delirium (PD) is associated with poor outcomes and increased health care costs. The incidence, outcomes, and cost of delirium for major urologic cancer surgeries have not been previously characterized in a population-based analysis.
We performed a population-based, retrospective cohort study of patients with PD at 490 US hospitals between 2003 and 2013 to evaluate the incidence, outcomes, and cost of delirium after radical prostatectomy, radical nephrectomy, partial nephrectomy, and radical cystectomy (RC). Delirium was defined using ICD-9 codes in combination with postoperative antipsychotics, sitters, and restraints. Regression models were constructed to assess mortality, discharge disposition, length of stay (LOS), and direct hospital admission costs. Survey-weighted adjustment for hospital clustering achieved estimates generalizable to the US population.
We identified 165,387 patients representing a weighted total of 1,097,355 patients. The overall incidence of PD was 2.7%, with the greatest incidence occurring after RC, with 6,268 cases (11%). Delirious patients had greater adjusted odds of in-hospital mortality (odds ratio [OR] = 3.65, P<0.001), 90-day mortality (OR = 1.47, P = 0.013), discharge with home health services (OR = 2.25, P<0.001), discharge to skilled nursing facilities (OR = 4.64, P<0.001), and a 0.9-day increase in median LOS (P<0.001). Patients with delirium also experienced a $2,697 increase in direct admission costs (P<0.001), with the greatest costs incurred in RC patients ($30,859 vs. $26,607; P<0.001).
Patients with PD after urologic cancer surgeries experienced worse outcomes, prolonged LOS, and increased admission costs. The greatest incidence and costs were seen after RC. Further research is warranted to identify high-risk patients and devise preventative strategies.
术后谵妄（PD）与不良预后及医疗费用增加相关。此前尚未在基于人群的分析中对主要泌尿外科癌症手术的谵妄发生率、预后及费用进行描述。
我们对2003年至2013年间美国490家医院的PD患者进行了一项基于人群的回顾性队列研究，以评估根治性前列腺切除术、根治性肾切除术、部分肾切除术及根治性膀胱切除术（RC）后谵妄的发生率、预后及费用。谵妄通过国际疾病分类第九版（ICD - 9）编码结合术后使用抗精神病药物、陪护及约束措施来定义。构建回归模型以评估死亡率、出院去向、住院时间（LOS）及直接住院费用。对医院聚类进行调查加权调整后得出可推广至美国人群的估计值。
我们识别出165,387例患者，加权后总计1,097,355例患者。PD的总体发生率为2.7%，其中RC后发生率最高，有6268例（11%）。谵妄患者院内死亡调整后比值比（OR） = 3.65，P < 0.001；90天死亡率（OR = 1.47，P = 0.013）；接受家庭健康服务出院（OR = 2.25，P < 0.001）；出院至专业护理机构（OR = 4.64，P < 0.001）；中位LOS增加0.9天（P < 0.001）。谵妄患者直接住院费用也增加了2697美元（P < 0.001），RC患者费用最高（30,859美元对26,607美元；P < 0.001）。
泌尿外科癌症手术后发生PD的患者预后更差、LOS延长且住院费用增加。RC后发生率及费用最高。有必要进一步研究以识别高危患者并制定预防策略。
