Ho Vanessa P, Towe Christopher W, Bensken Wyatt P, Pfoh Elizabeth, Dalton Jarrod, Connors Alfred F, Claridge Jeffrey A, Perzynski Adam T
Surgery, The MetroHealth System, Cleveland, Ohio, USA.
Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA.
Trauma Surg Acute Care Open. 2024 Jun 25;9(1):e001288. doi: 10.1136/tsaco-2023-001288. eCollection 2024.
The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.
We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.
Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).
Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.
III.
对于急诊普通外科（EGS）疾病（阑尾炎、憩室炎、胆囊炎、疝气、消化性溃疡、肠梗阻、缺血性肠病）实施外科手术干预的决策涉及多种因素的复杂考量，在老年人中尤为如此。我们假设，识别手术管理应用中的变异性可能会凸显出一条改善患者生存率和预后的潜在途径。
我们纳入了2016 - 2017年全国住院患者样本中年龄在65岁及以上的患有EGS疾病的成年人。手术管理通过手术编码确定。根据患者和医院因素（EGS诊断、年龄、性别、种族、休克状态、合并症以及医院EGS手术量）为每位患者计算接受手术可能性的倾向评分（PS）。使用PS临界值0.5定义手术低概率和高概率。我们确定了两个模型一致组（未手术 - 低概率、手术 - 高概率）和两个模型不一致组（未手术 - 高概率、手术 - 低概率）。逻辑回归估计每组住院死亡率的调整后比值比（AOR）。
在375546例入院患者中，21.2%接受了手术。模型不一致治疗发生在14.6%的患者中；5.9%的患者尽管PS高但未接受手术，8.7%的患者PS低却接受了手术。在调整后的回归分析中，模型不一致治疗与死亡率显著增加相关：未手术 - 高概率AOR为2.06（1.8
