慢性肢体威胁性缺血开放手术后长期结局的性别差异：健康保险索赔的倾向评分匹配分析。
Sex Disparities in Long Term Outcomes After Open Surgery for Chronic Limb Threatening Ischaemia: A Propensity Score Matched Analysis of Health Insurance Claims.
机构信息
Department of Vascular Medicine, Research Group GermanVasc, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
BARMER, Wuppertal, Germany.
出版信息
Eur J Vasc Endovasc Surg. 2021 Mar;61(3):423-429. doi: 10.1016/j.ejvs.2020.11.006. Epub 2020 Dec 15.
OBJECTIVE
Several studies suggest a disadvantage for women in peri-operative morbidity and mortality after open surgery in peripheral arterial occlusive disease. In addition to their heterogeneity regarding design and analysed cohorts, long term data are mostly missing. This study aimed to determine sex disparities in outcomes after open revascularisation in chronic limb threatening ischaemia (CLTI).
METHODS
Using health insurance claims data of the second largest insurance fund in Germany, BARMER, a large cohort of patients was sampled consecutively for analysis including index open surgical revascularisations of CLTI performed between 1 January 2010, and 31 December 2018. Propensity score matching was used to adjust for confounding. Sex related differences regarding overall survival, amputation free survival (AFS), and cardiovascular event free survival (CVEFS) during the five years after surgery were determined using Kaplan-Meier time to event curves, log rank test, logistic, and Cox regression.
RESULTS
Among 9 526 patients (49.5% women) in the entire cohort, 6 502 patients were matched. Before matching, women were older at presentation (78.0 vs. 71.8 years, p < .001) and suffered more often from multiple comorbidities (van Walraven score > 9, 55.5% vs. 50.6%, p < .001). During the hospital stay, there were 692 (7.3%) deaths, while 4 631 deaths (48.6%) occurred during the follow up. In the matched cohort, the median follow up was 746 days for women and 871 days for men. In the matched analyses, female sex was significantly associated with better overall survival (hazard ratio, HR, 0.80, log rank p < .001), AFS (HR 0.81, log rank p < .0001), and CVEFS (HR 0.84, log rank p < .001) five years after the index treatment.
CONCLUSION
In this largest propensity score matched analysis of health insurance claims to date from Germany, evidence was found for better long term outcomes in women after open surgical revascularisations for chronic limb threatening ischaemia. Future guidelines and studies should address the impact of sex on patient selection practice and outcomes to determine the underlying reasons for existing disparities.
目的
多项研究表明，女性在周围动脉闭塞性疾病（PAOD）开放手术后围手术期发病率和死亡率方面处于不利地位。除了在设计和分析队列方面存在异质性外，长期数据也大多缺失。本研究旨在确定在慢性肢体威胁性缺血（CLTI）的开放血运重建后，结局方面的性别差异。
方法
利用德国第二大保险公司 BARMER 的医疗保险索赔数据，连续抽取了一个大的患者队列进行分析，包括 2010 年 1 月 1 日至 2018 年 12 月 31 日期间进行的 CLTI 索引开放式血管重建术。使用倾向评分匹配来调整混杂因素。使用 Kaplan-Meier 时间事件曲线、对数秩检验、逻辑回归和 Cox 回归，确定手术后五年内全因生存率、无截肢生存率（AFS）和心血管事件无事件生存率（CVEFS）方面的性别差异。
结果
在整个队列的 9526 例患者（49.5%为女性）中，有 6502 例患者进行了匹配。匹配前，女性的年龄更大（78.0 岁比 71.8 岁，p<0.001），且更常患有多种合并症（van Walraven 评分>9，55.5%比 50.6%，p<0.001）。在住院期间，有 692 例（7.3%）死亡，而 4631 例（48.6%）死亡发生在随访期间。在匹配队列中，女性的中位随访时间为 746 天，男性为 871 天。在匹配分析中，女性的全因生存率（风险比，HR，0.80，对数秩 p<0.001）、AFS（HR，0.81，对数秩 p<0.0001）和 CVEFS（HR，0.84，对数秩 p<0.001）五年后明显更好。
结论
在这项迄今为止来自德国的最大的健康保险索赔倾向评分匹配分析中，证据表明，在慢性肢体威胁性缺血患者的开放血管重建术后，女性的长期结局更好。未来的指南和研究应解决性别对患者选择实践和结局的影响，以确定现有差异的潜在原因。
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