Prognostic Risk Modelling for Patients Undergoing Major Lower Limb Amputation: An Analysis of the UK National Vascular Registry
Prognostic Risk Modelling for Patients Undergoing Major Lower Limb Amputation: An Analysis of the UK National Vascular Registry
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DOI：
10.1016/j.ejvs.2019.12.006
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发表时间：
2020-04-01
影响因子：
5.7
通讯作者：
Twine，Christopher P.
中科院分区：
文献类型：
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作者：
Ambler，Graeme K.;Thomas-Jones，Emma;Twine，Christopher P.
下肢大截肢是血管外科中风险最高的下肢手术。尽管如此，很少有高质量的研究探讨了导致死亡的因素。其目的是确定独立的围手术期发病率和死亡率的风险因素，并制定可靠的模型估计risk.MethodsAll患者接受下肢截肢踝关节以上进入英国国家血管登记处（2014年1月至2016年12月）。使用多重插补处理缺失数据。开发模型，使用逻辑回归评估死亡率（主要结局）和发病率的独立风险因素，最大限度地减少贝叶斯信息标准，以平衡复杂性和模型拟合。伦理批准的研究被授予（威尔士REC 3参考：16/WA/0353）。总的来说，865例患者（9.1%）在出院前死亡。与死亡率相关的独立因素是急诊入院、双侧手术、年龄、美国麻醉医师协会分级、心电图异常、白色细胞计数或肌酐升高（所有均为p<0.01）。降低死亡率的独立因素是经胫骨手术、白蛋白增加或患者体重增加以及既往同侧血运重建手术（所有病例p<0.01）。结合这些因素的风险模型具有良好的区分度（C-统计量0.79，95%置信区间0.77-0.80）和出色的校准。发病率很高，分别有6.6%、9.7%和4.3%的患者患有心脏、呼吸和肾脏并发症。风险模型也预测发病率的结果（C-统计0.74，0.69，和0.74，分别）。一些潜在的可修改的因素，质量改进措施已被确定和准确的预测模型，可以帮助病人的咨询和决策已经制定。
ObjectiveMajor lower limb amputation is the highest risk lower limb procedure in vascular surgery. Despite this, few high quality studies have examined factors contributing to mortality. The aim was to identify independent risk factors for peri-operative morbidity and mortality and develop reliable models for estimating risk.MethodsAll patients undergoing lower limb amputation above the ankle entered into the UK National Vascular Registry (January 2014–December 2016) were included. Missing data were handled using multiple imputation. Models were developed to evaluate independent risk factors for mortality (the primary outcome) and morbidity using logistic regression, minimising the Bayesian information criterion to balance complexity and model fit. Ethical approval for the study was granted (Wales REC 3 ref:16/WA/0353).ResultsAll 9549 above ankle joint amputations in the registry were included. Overall, 865 patients (9.1%) died before leaving hospital. Independent factors associated with mortality were emergency admission, bilateral operation, age, American Society of Anesthesiologists' grade, abnormal electrocardiogram, and increased white cell count or creatinine (p< .01 for all). Independent factors reducing mortality were transtibial operation, increased albumin or patient weight, and previous ipsilateral revascularisation procedures (p< .01 for all). A risk model incorporating these factors had good discrimination (C-statistic 0.79, 95% confidence interval 0.77–0.80) and excellent calibration. Morbidity rates were high, with 6.6%, 9.7%, and 4.3% of patients suffering cardiac, respiratory, and renal complications, respectively. The risk model was also predictive of morbidity outcomes (C-statistics 0.74, 0.69, and 0.74, respectively).ConclusionMorbidity and mortality after lower limb amputation are high in the UK. Some potentially modifiable factors for quality improvement initiatives have been identified and accurate predictive models that could assist patient counselling and decision making have been developed.