Zogg Cheryl K, Falvey Jason R, Kodadek Lisa M, Staudenmayer Kristan L, Davis Kimberly A
From the Department of Surgery (C.K.Z., L.M.K., K.A.D.), Yale School of Medicine, New Haven, Connecticut; Department of Physical Therapy and Rehabilitation Science (J.R.F.), Department of Epidemiology & Public Health (J.R.F.), University of Maryland School of Medicine, Baltimore, Maryland; and Department of Surgery (K.L.S.), Stanford University Hospital, Sanford, California.
J Trauma Acute Care Surg. 2024 Mar 1;96(3):400-408. doi: 10.1097/TA.0000000000004191. Epub 2023 Nov 13.
When presenting for emergency general surgery (EGS) care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ("geriatric vulnerability") and the social determinants of health unique to the places in which they live ("neighborhood vulnerability"). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults.
Older adults, 65 years or older, hospitalized with an AAST-defined EGS condition were identified in the 2016 to 2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g., access to transportation).
A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six times greater risk of death (30-day risk-adjusted hazards ratio [HR], 6.32; 95% confidence interval [CI], 4.49-8.89). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to 15 times greater risk of death (30-day risk-adjusted HR, 15.12; 95% CI, 12.57-18.19). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day HRs for mortality of 11.53 (95% CI, 4.51-29.44) versus 40.67 (95% CI, 22.73-72.78). Similar patterns were seen for death within 365 days.
Both geriatric and neighborhood vulnerability have been shown to affect prehospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick.
Prognostic and Epidemiological; Level III.
在接受急诊普通外科（EGS）治疗时，由于与年龄相关的因素（“老年脆弱性”）以及他们所居住地区特有的健康社会决定因素（“邻里脆弱性”），老年人经常面临不良后果风险增加的情况。对于这些因素如何共同影响不良后果，人们知之甚少。我们试图探讨老年脆弱性和邻里脆弱性之间的相互作用如何影响老年人的EGS治疗结果。
在2016年至2019年、2021年佛罗里达州住院患者数据库中，识别出65岁及以上因美国创伤外科学会（AAST）定义的EGS疾病住院的老年人。潜在变量模型将患者年龄、多种疾病和医院虚弱风险评分的影响合并为一个“老年脆弱性”单一指标。然后，根据地区贫困指数、社会脆弱性指数及其相应子主题（如交通便利性）的差异所衡量的“邻里脆弱性”差异，比较老年脆弱性的变化。
共纳入448,968名老年人。对于居住在最不脆弱社区的患者，老年脆弱性增加导致死亡风险增加高达六倍（30天风险调整后危险比[HR]，6.32；95%置信区间[CI]，4.49 - 8.89）。在居住在最脆弱社区的患者中，这种影响增加了一倍多，老年脆弱性增加导致死亡风险增加高达15倍（30天风险调整后HR，15.12；95%CI，12.57 - 18.19）。当仅限于种族/族裔少数患者时，相乘效应高出四倍，导致相应的30天死亡率HR分别为11.53（95%CI，4.51 - 29.44）和40.67（95%CI，2二十二点七三至七十二点七八）。365天内死亡情况也呈现类似模式。
老年脆弱性和邻里脆弱性均已被证明会影响老年患者的院前风险。本研究结果在此基础上展开，首次深入探讨了这两个因素之间强大的相乘相互作用。结果表明，患者居住的地方可以从根本上改变EGS治疗的预期结果，使得原本脆弱性较低的患者在功能上等同于那些在基线时年龄更大、更虚弱、病情更重的患者。
预后和流行病学；三级。
