Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, Colo.
J Vasc Surg. 2021 May;73(5):1549-1556. doi: 10.1016/j.jvs.2020.10.005. Epub 2020 Oct 14.
Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score.
Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed.
Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset.
This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
血管手术后非家庭出院（NHD）至康复或熟练护理机构的情况描述不佳，尽管其对患者影响很大。了解术后 NHD 风险对于提供充分的术前咨询和共同决策至关重要，尤其是对于择期手术。我们旨在确定择期胸主动脉腔内修复术（TEVAR）治疗胸主动脉瘤（TAA）后 NHD 的独立预测因素，并创建一个临床有用的术前风险评分。
从 2014 年至 2018 年，从血管外科学会血管质量倡议中查询择期 TEVAR 治疗降主动脉 TAA 的病例。通过将数据集分成三分之二用于模型开发和三分之一用于验证，创建风险评分。在开发数据集上进行了一项简单的逐步分层多变量逻辑回归，控制医院水平的变异性，然后使用β系数为风险评分分配分数。然后对该评分进行交叉验证并评估模型性能。
总共纳入 1469 例患者，其中 213 例（14.5%）需要 NHD。基线时，需要 NHD 的患者更有可能≥80 岁（35.2% vs. 19.4%）、女性（58.7% vs. 40.6%）、功能依赖（42.3% vs. 24.0%）和贫血（46.5% vs. 27.8%），并且患有慢性阻塞性肺疾病（41.3% vs. 33.4%）、充血性心力衰竭（18.8% vs. 11.1%）和美国麻醉师协会分级≥4（51.6% vs. 39.8%；均 P<0.05）。在开发组的多变量分析中，确定了 NHD 的独立预测因素，并用于创建 18 分风险评分。根据风险评分将患者分为三组：低风险（0-7 分；n=563），NHD 率为 4.3%；中风险（8-11 分；n=701），NHD 率为 17.0%；高风险（≥12 分；n=205），NHD 率为 34.2%。该风险评分具有良好的预测能力，在开发数据集和验证数据集中的 C 统计量分别为 0.75 和 0.72。
本研究采用术前可识别的特征，使用一种新的风险评分可预测 TAA 的 TEVAR 后 NHD。该评分的使用可能有助于改善风险评估、术前咨询和共同决策。
