From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Ramadan, Kelz).
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Ramadan, Rosenbaum, Jain, Kelz, Fleisher, Silber).
J Am Coll Surg. 2023 May 1;236(5):1011-1022. doi: 10.1097/XCS.0000000000000659. Epub 2023 Mar 15.
Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.
We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.
Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795).
Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.
手术中的多种合并症很常见，并且与术后结局较差相关。然而，传统的多种合并症定义（≥2 种合并症）将绝大多数老年患者标记为多种合并症，从而限制了其临床应用。我们试图根据不同的合并症组合，制定和验证更适合外科专业的多种合并症定义。
我们使用了 Medicare 对 66 至 90 岁接受住院普通外科、骨科或血管外科手术的患者的索赔数据。使用 2016 年至 2017 年的数据，我们确定了所有与普通外科、骨科或血管外科手术相比，与 30 天死亡率增加至少 2 倍（普通外科/骨科）或 1.5 倍（血管外科）相关的所有合并症组合；我们称这些组合为合格的合并症组合。我们将其应用于 2018 年至 2019 年的数据（普通外科=230410 例患者，骨科=778131 例患者，血管外科=146570 例患者），以获得 30 天死亡率估计值。为了进一步验证，我们使用多元匹配测试了在资源更充足的医院（基于护理技能组合、手术量、教学地位）与其他所有医院中，多种合并症状态是否与患者的不同结局相关。
与传统的多种合并症定义相比，新定义标记的多种合并症患者要少得多：普通外科=85.0%（传统）比 55.9%（新）（p<0.0001）；骨科=66.6%比 40.2%（新）（p<0.0001）；血管外科=96.2%比 52.7%（新）（p<0.0001）。新定义的 30 天死亡率更高：普通外科=3.96%（传统）比 5.64%（新）（p<0.0001）；骨科=0.13%比 1.68%（新）（p<0.0001）；血管外科=4.43%比 7.00%（新）（p<0.0001）。资源更充足的医院为多种合并症患者提供的死亡率降低幅度明显大于其他所有医院，无论是普通外科还是骨科，而非血管外科，均如此（普通外科差值差异=-0.94%[-1.36%，-0.52%]，p<0.0001；骨科=-0.20%[-0.34%，-0.05%]，p=0.0087；血管外科=-0.12%[-0.69%，0.45%]，p=0.6795）。
我们的新多种合并症定义比传统定义更能明确识别出特定的、风险更高的患者群体，这可能有助于临床决策。
