Department of Urology, University of California, San Francisco, San Francisco, California.
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
J Urol. 2024 Sep;212(3):451-460. doi: 10.1097/JU.0000000000003978. Epub 2024 Jun 26.
Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist.
Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter values, were calculated to ensure the prognostic accuracy for postoperative complications.
In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit.
This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.
膀胱出口梗阻（BOO）在老年人中很常见。许多接受手术的老年人还存在其他影响手术风险的脆弱性因素，包括虚弱。一种基于虚弱程度预测 BOO 手术范围内手术结果的临床工具将有助于辅助手术决策，但目前尚不存在。
使用 Medicare 的 MedPAR、门诊和承运人文件，确定并分析了 2014 年至 2016 年接受 BOO 手术的 Medicare 受益人群。创建了 8 种不同的 BOO 手术类别。使用基于索赔的虚弱指数（CFI）为每位受益人群计算基线虚弱程度。将 CFI 中的 93 个变量和 Charlson 合并症指数中的 17 个变量逐个输入逐步逻辑回归模型，以确定对并发症最具预测性的变量。将相似和重复的变量合并为类别。计算校准曲线和模型拟合检验，包括 C 统计量、Brier 评分和 Spiegelhalter 值，以确保术后并发症的预测准确性。
共确定了 212543 名受益人群。大约 42.5%的人群处于虚弱前期（0.15 ≤ CFI < 0.25），8.7%的人群轻度虚弱（0.25 ≤ CFI < 0.35），1.2%的人群中度至重度虚弱（CFI ≥0.35）。使用逐步逻辑回归，确定了 13 个不同的预后变量类别，这些类别是术后结果最可靠的预测指标。大多数模型的判别和校准效果都很好，C 统计量和 Spiegelhalter 值分别较高，Brier 评分较低，表明准确性较高。每个结果的校准曲线都表现出良好的模型拟合。
这种新的风险评估工具可能有助于指导这一脆弱人群的手术预后。
