Goel Nicholas J, Iyengar Amit, Kelly John J, Han Jason J, Brown Chase R, Desai Nimesh D
Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa.
Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa.
J Thorac Cardiovasc Surg. 2022 Jan;163(1):151-160.e6. doi: 10.1016/j.jtcvs.2020.04.097. Epub 2020 May 4.
Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery.
We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients.
In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions.
In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.
来自大型非心脏手术的最新数据表明，相比总体手术量，医院的虚弱患者数量能更好地预测虚弱患者的手术结局。我们试图评估心脏手术患者中的“虚弱患者数量 - 虚弱结局关系”。
我们使用全国再入院数据库研究了2010年至2014年间接受冠状动脉搭桥术或瓣膜置换手术的72818名虚弱患者。使用约翰霍普金斯调整临床组虚弱定义诊断指标来定义虚弱。多水平逻辑回归用于评估按四分位数划分的虚弱患者数量对虚弱患者的死亡率、手术并发症、抢救失败、非回家出院、30天再入院率、住院时间和住院费用的独立影响。
将最高四分位数与最低四分位数进行比较时，总体心脏手术量和虚弱患者数量均与较短的住院时间和降低的费用显著相关。然而，虚弱患者数量还与显著降低的院内死亡率（比值比，0.79；95%置信区间，0.67 - 0.94；P = 0.006）和抢救失败（比值比，0.83；95%置信区间，0.70 - 0.98；P = 0.03）独立相关，而总体手术量与死亡率（比值比，0.94；95%置信区间，0.74 - 1.10；P = 0.43）或抢救失败（比值比，0.98；95%置信区间，0.83 - 1.17；P = 0.85）之间均未发现此类关联。虚弱患者数量和总体手术量与30天再入院率均无显著关系。
在接受心脏手术的虚弱患者中，虚弱患者的手术量是院内死亡率和抢救失败的重要独立预测因素，而总体手术量则不是。因此，在患有心脏病的虚弱患者中，“虚弱患者数量 - 结局关系”取代了传统的“手术量 - 结局关系”。
