Division of Vascular Surgery, University of Florida, Gainesville, Fla.
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Mass.
J Vasc Surg. 2020 May;71(5):1685-1690.e2. doi: 10.1016/j.jvs.2019.07.087. Epub 2019 Nov 6.
Dementia has been associated with increased complications and mortality in orthopedics and other surgical specialties, but has received limited attention in vascular surgery. Therefore, we evaluated the association of dementia with surgical outcomes for elderly patients with Medicare who underwent a variety of open and percutaneous vascular surgery procedures.
We reviewed claims data from the Centers for Medicare and Medicaid Services for beneficiaries enrolled in Medicare Part A fee-for-service insurance from January 1, 2011, to December 31, 2011, who underwent inpatient vascular surgery. Only the first surgery during the first admission was considered for analysis. Traditional outcomes (30- and 90-day mortality, intensive care admission, complications, length of stay) and patient-centered outcomes (discharge to home, extended skilled nursing facility [SNF] stay, time at home) were adjusted for patient and procedure characteristics using multilevel linear or logistic regression as appropriate. All analyses were performed using SAS (v9.4, SAS Institute Inc, Cary, NC).
Our study included 210,918 patients undergoing vascular surgery, of whom 27,920 carried a diagnosis of dementia. The average age of the entire cohort was 75.74 years, and 55.43% were male. Patients with dementia were older and had higher rates of comorbidities compared with patients without a dementia diagnosis. The three most common defined classes of intervention excluding miscellaneous ones were cerebrovascular, peripheral arterial, and aortic cases, which jointly accounted for 53.15% of cases. Among all cases, 56.62% were open. Emergent/urgent cases were more frequent amongst those with dementia (60.66% vs 37.93%; P < .001). After adjustment, patients with dementia had increased odds of 30-day mortality (odds ratio [OR], 1.21; P < .0001) and 90-day mortality (OR, 1.63; P < .0001), extended SNF stay (OR, 3.47; P < .0001), and longer hospital length of stay (8.29 days vs 5.41 days; P < .001). They were less likely to be discharged home (OR, 0.31; P < .0001) and spent a lower fraction of time at home after discharge (63.29% vs 86.91%; P < .001). Intensive care admission and inpatient complications were similar between the two groups.
Dementia is associated with poor traditional outcomes, including increased 30- and 90-day mortality and longer hospital lengths of stay in this large national patient sample. It is also associated with worse patient-centered outcomes, including substantially lower discharge rates to home, less time spent at home after discharge, and higher rates of extended stay in a SNF. These data should be used to counsel patients facing vascular surgery to provide goal-concordant care, particularly to patients with dementia.
痴呆与骨科和其他外科专业的并发症和死亡率增加有关，但在血管外科学中受到的关注有限。因此，我们评估了痴呆症与接受各种开放式和经皮血管外科手术的 Medicare 老年患者手术结果之间的关联。
我们审查了 2011 年 1 月 1 日至 2011 年 12 月 31 日期间参加 Medicare 部分 A 按服务收费保险的 Medicare 受益人的医疗保险和医疗补助服务中心索赔数据，这些患者接受了住院血管外科手术。仅考虑第一次入院期间的第一次手术进行分析。使用多级线性或逻辑回归适当地调整患者和手术特征的传统结果（30 天和 90 天死亡率、重症监护入院、并发症、住院时间）和以患者为中心的结果（出院回家、延长熟练护理设施 [SNF] 停留时间、在家时间）。所有分析均使用 SAS（v9.4，SAS Institute Inc，Cary，NC）进行。
我们的研究包括 210918 名接受血管外科手术的患者，其中 27920 名患者患有痴呆症。整个队列的平均年龄为 75.74 岁，55.43%为男性。与没有痴呆诊断的患者相比，痴呆症患者年龄更大，合并症发生率更高。除杂项外，最常见的三类定义干预措施是脑血管、周围动脉和主动脉病例，共占病例的 53.15%。在所有病例中，56.62%为开放性。有痴呆症的紧急/紧急病例更为常见（60.66%比 37.93%；P<.001）。调整后，痴呆症患者 30 天死亡率（比值比 [OR]，1.21；P<.0001）和 90 天死亡率（OR，1.63；P<.0001）、延长 SNF 停留时间（OR，3.47；P<.0001）和住院时间延长（8.29 天比 5.41 天；P<.001）的几率增加。他们更不可能出院回家（OR，0.31；P<.0001），出院后在家的时间比例也较低（63.29%比 86.91%；P<.001）。两组之间的重症监护入院和住院并发症相似。
在这个大型全国患者样本中，痴呆症与传统结局较差有关，包括 30 天和 90 天死亡率增加和住院时间延长。它还与以患者为中心的结局较差有关，包括出院回家率明显降低、出院后在家时间减少以及在 SNF 延长停留率较高。这些数据应用于为面临血管外科手术的患者提供咨询，以提供与目标一致的护理，特别是对痴呆症患者。
