The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis.
The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis.
复制标题
多种发病率对紧急普通外科手术与非手术治疗的条件影响：使用工具变量分析的回顾性观察研究。
DOI：
10.1097/sla.0000000000005901
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发表时间：
2023
影响因子：
9
通讯作者：
Kelz,RachelR
中科院分区：
文献类型：
--
作者：
Rosen,ClaireB;Roberts,SanfordE;Wirtalla,ChrisJ;Keele,LukeJ;Kaufman,ElinoreJ;Halpern,ScottD;Reilly,PatrickM;Neuman,MarkD;Kelz,RachelR
目的：了解多发病如何影响急诊普通外科 (EGS) 情况的手术与非手术治疗。背景：EGS 是一个异质领域，包括手术和非手术治疗方案。对于患有多种疾病的老年患者来说，决策尤其复杂。方法：这项针对医疗保险受益人的全国性回顾性观察队列研究采用工具变量方法和远近匹配，检查了多种疾病的条件影响（使用合格的合并症集定义）对 EGS 疾病的手术与非手术治疗的影响。结果：在 507,667 名患有 EGS 疾病的患者中，155,493 (30.6%) 接受了手术。总体而言，278,836 人（54.9%）患有多种疾病。调整后，多发病显着增加了普通腹部患者（+ 9.8%；P= 0.002）和上消化道患者（+ 19.9%，P< 0.001）与手术治疗相关的院内死亡风险以及30天死亡率（+ 27.7%，P< 0.001）和非常规出院（+ 21.8%，P= 0.007）与上消化道患者的手术治疗相关。无论多病状态如何，手术治疗与结直肠患者院内死亡风险较高相关（多病：+ 12%，P < 0.001；非多病：+ 4%，P = 0.003），结直肠患者非常规出院风险较高（多病：+ 42.3%，P < 0.001；非多病：+ 55.1%，P < 0.001）和肠梗阻患者（多病：+ 14.6%，P= 0.001；非多病：+ 14.8%，P= 0.001），非常规出院风险较低（多病：− 11.5%，P< 0.001；非多病：− 11.9%，P< 0.001）和 30 天再入院肝胆疾病患者中（多病：− 8.2%，P= 0.002；非多病：− 9.7%，P < 0.001）。 结论：多病对手术与非手术治疗的影响因 EGS 病情类别而异。医生和患者应该就治疗方案的预期风险和益处进行诚实的对话，未来的研究应该旨在了解多病 EGS 患者的最佳治疗。
Objective:To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions.Background:EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity.Methods: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.Results: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.Conclusions: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.