Podmore Bélène, Hutchings Andrew, van der Meulen Jan, Aggarwal Ajay, Konan Sujith
Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
BMJ Open. 2018 Jul 11;8(7):e021784. doi: 10.1136/bmjopen-2018-021784.
To systematically perform a meta-analysis of the association between different comorbid conditions on safety (short-term outcomes) and effectiveness (long-term outcomes) in patients undergoing hip and knee replacement surgery.
Systematic review and meta-analysis.
Medline, Embase and CINAHL Plus were searched up to May 2017. We included all studies that reported data to allow the calculation of a pooled OR for the impact of 11 comorbid conditions on 10 outcomes (including surgical complications, readmissions, mortality, function, health-related quality of life, pain and revision surgery). The quality of included studies was assessed using a modified Newcastle-Ottawa Scale. Continuous outcomes were converted to ORs using the Hasselblad and Hedges approach. Results were combined using a random-effects meta-analysis.
The primary outcome was the adjusted OR for the impact of each 11 comorbid condition on each of the 10 outcomes compared with patients without the comorbid condition. Where the adjusted OR was not available the secondary outcome was the crude OR.
70 studies were included with 16 (23%) reporting on at least 100 000 patients and 9 (13%) were of high quality. We found that comorbidities increased the short-term risk of hospital readmissions (8 of 11 conditions) and mortality (8 of 11 conditions). The impact on surgical complications was inconsistent across comorbid conditions. In the long term, comorbid conditions increased the risk of revision surgery (6 of 11 conditions) and long-term mortality (7 of 11 conditions). The long-term impact on function, quality of life and pain varied across comorbid conditions.
This systematic review shows that comorbidities predominantly have an impact on the safety of hip and knee replacement surgery but little impact on its effectiveness. There is a need for high-quality studies also considering the severity of comorbid conditions.
对髋关节和膝关节置换手术患者不同合并症与安全性（短期结局）和有效性（长期结局）之间的关联进行系统的荟萃分析。
系统评价和荟萃分析。
检索截至2017年5月的Medline、Embase和CINAHL Plus数据库。我们纳入了所有报告数据的研究，以便计算11种合并症对10种结局（包括手术并发症、再入院、死亡率、功能、健康相关生活质量、疼痛和翻修手术）影响的合并比值比。使用改良的纽卡斯尔-渥太华量表评估纳入研究的质量。连续结局采用哈塞尔布拉德和赫奇斯方法转换为比值比。结果采用随机效应荟萃分析进行合并。
主要结局是与无合并症患者相比，11种合并症中每种合并症对10种结局中每种结局影响的调整后比值比。若无法获得调整后比值比，则次要结局为粗比值比。
纳入70项研究（其中16项（23%）报告的患者至少有100000例，9项（13%）质量较高）。我们发现合并症增加了短期再入院风险（11种情况中的8种）和死亡率（11种情况中的8种）。合并症对手术并发症的影响在不同合并症中不一致。从长期来看，合并症增加了翻修手术风险（11种情况中的6种）和长期死亡率（11种情况中的7种）。合并症对功能、生活质量和疼痛的长期影响因合并症而异。
本系统评价表明，合并症主要影响髋关节和膝关节置换手术的安全性，但对其有效性影响较小。还需要高质量的研究，同时考虑合并症的严重程度。
