Division of Trauma, Burn, and Surgical Critical Care, Surgery Department, Brigham and Women's Hospital, Boston, Massachusetts.
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Surg. 2021 Jan 1;156(1):68-74. doi: 10.1001/jamasurg.2020.5397.
In this aging society, older patients are more commonly undergoing emergency general surgery (EGS). Although frailty has been associated with worse outcomes in this population, EGS encompasses a heterogeneous mix of procedures.
To determine if the association of frailty with morbidity and mortality in EGS patients varies based on the level of procedural risk.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed Medicare inpatient claims file (January 2007-December 2015) and included all inpatients who underwent 1 of 7 previously described EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Analysis took place from September 2019 to January 2020.
The primary exposure of interest was risk procedural level. EGS procedures were stratified as high risk (excision of small intestine, excision of large intestine, peptic ulcer repair, lysis of peritoneal adhesions, and laparotomy) and low risk (appendectomy and cholecystectomy).
The primary outcome was overall 30-day mortality after discharge. Frailty was assessed using a claims-based frailty index. Multivariate logistic regression analysis was used and was stratified by risk level.
A total of 882 929 EGS patients were included in this study (mean [SD] age, 77.9 [7.5] years; 483 637 [54%] were female). Overall mortality was 4.5% (n = 40 304). The frailty index classified 12.6% (n = 111 513) of patients as frail, and mortality within this group was 9.9% (n = 11 307). High-risk procedures represented 53% (n = 468 098) of the caseload, and mortality was 6.8% (n = 31 979). For low-risk procedures, mortality was 2% (n = 8325). Frailty was significantly associated with mortality (odds ratio, 1.64; 95% CI, 1.60-1.68). After stratified analysis, this association remained significant for high-risk (odds ratio, 1.53; 95% CI, 1.49-1.58) and low-risk (odds ratio, 2.05; 95% CI, 1.94-2.17) procedures.
Frailty was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures.
在这个老龄化社会中，越来越多的老年患者接受急诊普通外科（EGS）治疗。尽管虚弱与该人群的不良预后相关，但 EGS 涵盖了各种不同的手术程序。
确定虚弱与 EGS 患者发病率和死亡率的相关性是否因手术风险水平而异。
设计、地点和参与者：这项横断面研究分析了 Medicare 住院索赔文件（2007 年 1 月至 2015 年 12 月），包括所有接受过之前描述的 7 种 EGS 程序之一的住院患者，这些程序代表了全国 80%的 EGS 量、并发症和死亡率。分析于 2019 年 9 月至 2020 年 1 月进行。
主要感兴趣的暴露是手术风险水平。EGS 手术分为高风险（小肠切除术、大肠切除术、胃溃疡修复术、腹膜粘连松解术和剖腹术）和低风险（阑尾切除术和胆囊切除术）。
主要结局是出院后 30 天的总体死亡率。使用基于索赔的虚弱指数评估虚弱。使用多变量逻辑回归分析，并按风险水平分层。
共有 882929 例 EGS 患者纳入本研究（平均[标准差]年龄，77.9[7.5]岁；483637[54%]为女性）。总死亡率为 4.5%（n=40304）。虚弱指数将 12.6%（n=111513）的患者归类为虚弱，该组的死亡率为 9.9%（n=11307）。高风险手术占病例的 53%（n=468098），死亡率为 6.8%（n=31979）。对于低风险手术，死亡率为 2%（n=8325）。虚弱与死亡率显著相关（比值比，1.64；95%置信区间，1.60-1.68）。分层分析后，这种相关性在高风险（比值比，1.53；95%置信区间，1.49-1.58）和低风险（比值比，2.05；95%置信区间，1.94-2.17）手术中仍然显著。
虚弱与 EGS 患者的死亡率显著相关，在低风险手术中相关性更强。即使在低风险手术中，术前虚弱评估也至关重要。
