Boitano Laura T, Iannuzzi James C, Tanious Adam, Mohebali Jahan, Schwartz Samuel I, Chang David C, Clouse W Darrin, Conrad Mark F
Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA.
Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA.
Ann Vasc Surg. 2019 May;57:109-117. doi: 10.1016/j.avsg.2018.12.058. Epub 2019 Jan 26.
There is a paucity of data guiding preoperative counseling on the need for discharge to a facility or nonhome discharge (NHD) following elective endovascular repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]). This study seeks to determine the preoperative predictors of NHD following EVAR in baseline home-dwelling patients and to determine whether NHD is associated with major postdischarge complications and readmission.
This retrospective cohort study utilized the National Surgical Quality Improvement Program Vascular Procedure Targeted database to identify elective EVAR cases admitted from home (2011 to 2015). The primary end point was NHD. A multivariable logistic regression model was used to determine predictive preoperative factors for NHD and to determine whether NHD predicted major postdischarge complications and readmission.
Overall 6,276 cases were included; 291 (4.6%) required NHD. NHD were more frequently female, anemic, functionally dependent, nonsmokers, had chronic obstructive pulmonary disease, recent congestive heart failure exacerbation, and open baseline wounds. NHD was associated with complex surgery, indicated by operative time more than the median, 2.5 hr. Significant predictors for NHD on multivariable analysis included female sex (odds ratio [OR]: 2.2, confidence interval [CI]: 1.7-2.9, P < 0.001), octogenarians (OR: 5.7 CI: 2.3-14.1; P < 0.001) and nonagenarians (OR: 14.6, CI: 5.4-39.2; P < 0.001), dependent functional status (OR: 5.4, CI: 3.3-8.8; P < 0.001), preoperative open wound (OR: 3.5, CI: 1.4-8.9; P = 0.006), high operative time (OR: 2.7, CI: 2.0-3.6; P < 0.001), and hypogastric embolization (OR: 1.6, CI: 1.1-2.1 P = 0.022), C-statistic = 0.780. On adjusted analysis, NHD did not independently predict major postdischarge complication (OR: 1.0 CI: 0.6-1.9; P = 0.875) or unplanned readmission (OR 1.0, CI: 0.6-1.5, P = 0.842).
Discharge to skilled facility following EVAR can be predicted using preoperative factors. Future studies should seek to validate these findings in a prospective manner. Identifying high-risk patients' NHD can help define expectations and facilitate early referral to skilled facilities that may reduce hospital length of stay, reducing health-care costs.
关于腹主动脉瘤择期血管腔内修复术（血管腔内动脉瘤修复术[EVAR]）后出院至医疗机构或非家庭出院（NHD）需求的术前咨询数据匮乏。本研究旨在确定基线居家患者EVAR术后NHD的术前预测因素，并确定NHD是否与出院后主要并发症及再入院相关。
这项回顾性队列研究利用国家外科质量改进计划血管手术目标数据库，识别2011年至2015年从家中收治的择期EVAR病例。主要终点为NHD。采用多变量逻辑回归模型确定NHD的术前预测因素，并确定NHD是否能预测出院后主要并发症及再入院情况。
共纳入6276例病例；291例（4.6%）需要NHD。NHD患者女性、贫血、功能依赖、非吸烟者、患有慢性阻塞性肺疾病、近期充血性心力衰竭加重及基线伤口开放的情况更为常见。NHD与复杂手术相关，手术时间超过中位数2.5小时即表明手术复杂。多变量分析中NHD的显著预测因素包括女性（比值比[OR]：2.2，置信区间[CI]：1.7 - 2.9，P < 0.001）、八旬老人（OR：5.7，CI：2.3 - 14.1；P < 0.001）和九旬老人（OR：14.6，CI：5.4 - 39.2；P < 0.001）、功能依赖状态（OR：5.4，CI：3.3 - 8.8；P < 0.001）、术前伤口开放（OR：3.5，CI：1.4 - 8.9；P = 0.006）、手术时间长（OR：2.7，CI：2.0 - 3.6；P < 0.001）以及下腹栓塞（OR：1.6，CI：1.1 - 2.1，P = 0.022），C统计量 = 0.780。经校正分析，NHD并不能独立预测出院后主要并发症（OR：1.0，CI：0.6 - 1.9；P = 0.875）或计划外再入院（OR 1.0，CI：0.6 - 1.5，P = 0.842）。
可利用术前因素预测EVAR术后转至专业机构的出院情况。未来研究应以前瞻性方式验证这些发现。识别NHD的高危患者有助于明确预期，并促进早期转诊至可能缩短住院时间、降低医疗成本得专业机构。
