Kaplan Harrison J, Leitman I Michael
Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1076, New York, NY, 10029, USA.
Ann Med Surg (Lond). 2022 Apr 8;77:103516. doi: 10.1016/j.amsu.2022.103516. eCollection 2022 May.
Splenectomy, still a commonly performed treatment for splenic injury in trauma patients, has been shown to have a high rate of complications. The purpose of this study was to identify predictors, including race and insurance status, associated with adverse outcomes post-splenectomy in trauma patients. We discuss possible explanations and methods for reducing these disparities.
The American College of Surgeons - Trauma Quality Improvement Program (ACS-TQIP) participant user database was queried from 2010 to 2015 and patients who underwent total splenectomy were identified. All mechanisms of injury, including both blunt and penetrating trauma, were included. Patients with advance directives limiting care or aged under 18 were excluded. Propensity score matching was used to control for age, preexisting medical conditions, and the severity of the traumatic injury. A chi-squared test was used to find significant associations between available predictors and outcomes for this cross-sectional study.
The post-splenectomy mortality rate was 9.2% (n = 1047), 8.0% (n = 918) of patients had three or more complications, and 20.3% (n = 2315) had major complications. A primary race of white (OR 0.7, 95% Confidence Interval (CI) 0.6-0.9, p < 0.01) and private insurance (OR 0.5, 95%CI 0.4-0.6, p < 0.01) were associated with lower risks of mortality A primary race of neither Black nor white (OR 1.3, 95%CI 1.03-1.7, p = 0.03) and a lack of health insurance ("self-pay") (OR 1.6, 95%CI 1.3-1.9, p < 0.01) were both correlated with mortality. When limited to hospitals of 600+ beds, there were no associations between race and mortality.
The post-splenectomy mortality rate after trauma remains high. In U.S. trauma centers, a primary race of Black and payment status of "self-pay" are associated with adverse outcomes after splenectomy following a traumatic injury. These disparities are reduced when limiting analysis to larger hospitals. Efforts to reduce disparities in outcomes among trauma patients requiring a splenectomy should focus on improving resource availability and quality in smaller hospitals.
脾切除术仍是创伤患者脾损伤的常用治疗方法，但已显示出较高的并发症发生率。本研究的目的是确定与创伤患者脾切除术后不良结局相关的预测因素，包括种族和保险状况。我们讨论了减少这些差异的可能解释和方法。
查询了2010年至2015年美国外科医师学会创伤质量改进项目（ACS-TQIP）参与者用户数据库，确定了接受全脾切除术的患者。纳入了所有损伤机制，包括钝性和穿透性创伤。排除有预先指示限制治疗或年龄在18岁以下的患者。倾向评分匹配用于控制年龄、既往病史和创伤损伤的严重程度。采用卡方检验来发现本横断面研究中可用预测因素与结局之间的显著关联。
脾切除术后死亡率为9.2%（n = 1047），8.0%（n = 918）的患者有三种或更多并发症，20.3%（n = 2315）有严重并发症。白人种族（比值比[OR]0.7，95%置信区间[CI]0.6 - 0.9，p < 0.01）和私人保险（OR 0.5，95%CI 0.4 - 0.6，p < 0.01）与较低的死亡风险相关。非黑非白的种族（OR 1.3，95%CI 1.03 - 1.7，p = 0.03）和缺乏医疗保险（“自费”）（OR 1.6，95%CI 1.3 - 1.9，p < 0.01）均与死亡率相关。当仅限于600张及以上床位的医院时，种族与死亡率之间无关联。
创伤后脾切除术后死亡率仍然很高。在美国创伤中心，黑人种族和“自费”支付状况与创伤后脾切除术后的不良结局相关。当将分析限于较大医院时，这些差异会减小。减少需要脾切除术的创伤患者结局差异的努力应集中在改善较小医院的资源可用性和质量上。
