Department of Surgery, Hospital of the University of Pennsylvania.
Department of Medicine, Hospital of the University of Pennsylvania.
Ann Surg. 2023 Oct 1;278(4):e855-e862. doi: 10.1097/SLA.0000000000005901. Epub 2023 May 22.
To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions.
EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity.
Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions.
Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients.
The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.
了解多种合并症如何影响急诊普通外科 (EGS) 疾病的手术与非手术治疗。
EGS 是一个异质领域，包括手术和非手术治疗选择。对于有多发性合并症的老年患者，决策尤其复杂。
本研究采用基于工具变量的近-远匹配方法，对医疗保险受益人的全国性回顾性观察队列进行研究，调查了使用合格合并症集定义的多发性合并症对 EGS 疾病手术与非手术管理的条件影响。
在 507667 例 EGS 疾病患者中，有 155493 例（30.6%）接受了手术。总体而言，278836 例（54.9%）有多发性合并症。调整后，多发性合并症显著增加了一般腹部患者手术治疗相关的院内死亡率风险（增加 9.8%；P=0.002）和上消化道患者手术治疗相关的院内死亡率风险（增加 19.9%；P<0.001），以及上消化道患者手术治疗相关的 30 天死亡率风险（增加 27.7%；P<0.001）和非常规出院风险（增加 21.8%；P=0.007）。无论多发性合并症状态如何，手术治疗与结直肠患者的院内死亡率风险增加相关（多发性合并症：增加 12%；P<0.001；非多发性合并症：增加 4%；P=0.003），与结直肠（多发性合并症：增加 42.3%；P<0.001；非多发性合并症：增加 55.1%；P<0.001）和肠梗阻患者的非常规出院风险增加相关（多发性合并症：增加 14.6%；P=0.001；非多发性合并症：增加 14.8%；P=0.001），与肝胆患者的非常规出院风险降低相关（多发性合并症：降低 11.5%；P<0.001；非多发性合并症：降低 11.9%；P<0.001）和 30 天再入院风险降低相关（多发性合并症：降低 8.2%；P=0.002；非多发性合并症：降低 9.7%；P<0.001）。
多发性合并症对 EGS 疾病手术与非手术治疗的影响因疾病类别而异。医生和患者应该就治疗方案的预期风险和益处进行坦诚的对话，未来的研究应旨在了解多发性 EGS 患者的最佳治疗管理。
