Madrigal Josef, Hadaya Joseph, Lee Cory, Tran Zachary, Benharash Peyman
Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
J Am Med Dir Assoc. 2022 Apr;23(4):684-689.e1. doi: 10.1016/j.jamda.2022.02.004. Epub 2022 Mar 15.
Risk of mortality and major comorbidity remains high following hepatic resection. Given recent advancements in nonsurgical techniques to control hepatic malignancy, accurate assessment of surgical candidates, especially those considered frail, has become imperative. The present study aimed to characterize the impact of frailty on clinical and financial outcomes following hepatic resection in older individuals.
Retrospective cohort study.
All older adults (≥65 years) undergoing elective hepatic resection were identified from the 2012 to 2019 National Inpatient Sample.
Frailty was defined by using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Multivariable regression models were developed to assess the independent association of frailty with mortality, perioperative complications, and resource utilization. Marginal effects were tabulated to assess the impact of hospital volume on frailty-associated mortality.
Of an estimated 40,735 patients undergoing major hepatic resection, 9.0% were considered frail. After multivariable adjustment, frailty was associated with increased odds of mortality (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 2.0-4.3; P < .001) and perioperative complication (AOR 2.9; 95% CI 2.4-3.4; P < .001). Furthermore, frail patients incurred longer risk-adjusted length of stay (14.2 vs 6.7 days, P < .001) and greater hospitalization costs ($55,100 vs $29,300, P < .001). In assessing the impact of institutional expertise on perioperative outcomes, the marginal effect of frailty on mortality became less pronounced with increasing operative volume.
As the population of the United States continues to age, surgeons are increasingly likely to encounter candidates for major hepatic resection who are frail. The present study associated frailty with inferior clinical and financial outcomes; however, frailty-associated mortality became less pronounced at centers with high hepatic resection operative volume. Coding-based instruments, such as the Johns Hopkins Adjusted Clinical Groups, may identify patients from electronic medical records who may benefit from further geriatric assessment and targeted treatments.
肝切除术后死亡风险和主要合并症仍然很高。鉴于控制肝脏恶性肿瘤的非手术技术最近取得了进展，准确评估手术候选人，尤其是那些被认为身体虚弱的人，变得势在必行。本研究旨在描述身体虚弱对老年个体肝切除术后临床和经济结果的影响。
回顾性队列研究。
从2012年至2019年全国住院患者样本中确定所有接受择期肝切除的老年人（≥65岁）。
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。建立多变量回归模型以评估虚弱与死亡率、围手术期并发症和资源利用之间的独立关联。列出边际效应以评估医院手术量对虚弱相关死亡率的影响。
在估计的40,735例接受大肝切除的患者中，9.0%被认为身体虚弱。经过多变量调整后，虚弱与死亡率增加的几率相关（调整后的优势比[AOR]为2.9；95%置信区间[CI]为2.0-4.3；P<.001）和围手术期并发症（AOR为2.9；95%CI为2.4-3.4；P<.001）。此外，虚弱患者的风险调整住院时间更长（14.2天对6.7天，P<.001），住院费用更高（55,100美元对29,300美元，P<.001）。在评估机构专业知识对围手术期结果的影响时，随着手术量的增加，虚弱对死亡率的边际效应变得不那么明显。
随着美国人口持续老龄化，外科医生越来越有可能遇到身体虚弱的大肝切除手术候选人。本研究将虚弱与较差的临床和经济结果相关联；然而，在肝切除手术量高的中心，虚弱相关的死亡率变得不那么明显。基于编码的工具，如约翰霍普金斯调整临床组，可能会从电子病历中识别出可能受益于进一步老年评估和靶向治疗的患者。
