Preoperative dementia is associated with increased cost and complications after vascular surgery
Preoperative dementia is associated with increased cost and complications after vascular surgery
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DOI：
10.1016/j.jvs.2018.01.032
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发表时间：
2018-10-01
影响因子：
4.3
通讯作者：
Upchurch, Gilbert R., Jr.
中科院分区：
文献类型：
--
作者：
Mehaffey, J. Hunter;Hawkins, Robert B.;Upchurch, Gilbert R., Jr.
目的：痴呆是内科并发症的主要危险因素，与手术后并发症的发生率较高有关。考虑到血管疾病的全身性，内科合并症显著增加了血管手术后的费用和并发症。我们假设痴呆的存在是血管外科手术后术后并发症增加和医疗费用增加的独立预测因素。方法：对2012年至2017年在单一学术医疗中心接受血管外科手术的所有患者的血管质量倡议数据库进行查询。包括所有模块（开放性腹主动脉瘤、腹股沟上旁路、下肢旁路、截肢、颈动脉内膜切除术、主动脉瘤腔内修复术、胸主动脉瘤腔内修复术和外周血管内介入）。查询一个机构临床数据库，以确定患者的国际疾病分类，第九次修订诊断代码痴呆症以及总住院费用和长期生存使用社会保障记录从弗吉尼亚州卫生部。分层逻辑回归和线性回归模型被用来评估任何并发症和通货膨胀调整成本的风险调整预测因素。Kaplan-Meier和考克斯比例风险模型用于生存analysis.Results：共2318例患者接受血管手术，并在过去5年中捕获的血管质量倡议，88（3.8%）有痴呆症的诊断。痴呆患者年龄较大，合并症发生率较高，最常见的手术是大截肢。此外，痴呆患者的任何并发症发生率均显著较高（52% vs 16%; P <0.0001），90天死亡率增加（14% vs 4.8%; P = 0.0002）。此外，痴呆与显著的资源利用相关，包括术前住院时间（LOS）、术后LOS、重症监护室LOS和通货膨胀调整后的总住院费用（均P < .0001）。分层模型显示，痴呆是任何并发症的最强术前预测因子（比值比，8.64; P < .0001），对总住院费用的风险调整影响最大（22，069美元; P < .0001）。最后，生存分析表明，痴呆症与血管手术后生存率降低独立相关（风险比，1.37; P = 0.018）。结论：本研究表明，痴呆症是血管手术后任何并发症和住院费用增加的最强预测因子之一。考虑到临床和经济疾病的高风险，痴呆症患者在接受血管手术前应仔细考虑和咨询。
Objective: Dementia represents a major risk factor for medical complications and has been linked to higher rates of complication after surgery. Given the systemic nature of vascular disease, medical comorbidities significantly increase cost and complications after vascular surgery. We hypothesize that the presence of dementia is an independent predictor of increased postoperative complications and higher health care costs after vascular surgery.Methods: The Vascular Quality Initiative database was queried for all patients undergoing vascular surgery at a single academic medical center from 2012 to 2017. All modules were included (open abdominal aortic aneurysm, suprainguinal bypass, lower extremity bypass, amputation, carotid endarterectomy, endovascular aortic aneurysm repair, thoracic endovascular aortic aneurysm repair, and peripheral endovascular intervention). An institutional clinical data repository was queried to identify patients with International Classification of Diseases, Ninth Revision diagnosis codes for dementia as well as total hospital cost and long-term survival using Social Security records from the Virginia Department of Health. Hierarchical logistic and linear regression models were fit to assess risk-adjusted predictors of any complication and inflation-adjusted cost. Kaplan-Meier and Cox proportional hazards models were used for survival analysis.Results: A total of 2318 patients underwent vascular surgery and were captured by the Vascular Quality Initiative during the past 5 years, with 88 (3.8%) having a diagnosis of dementia. Patients with dementia were older and had higher rates of medical comorbidities, and the most common procedure was major amputation. In addition, dementia patients had a significantly higher rate of any complication (52% vs 16%; P < .0001) and increased 90-day mortality (14% vs 4.8%; P = .0002). Furthermore, dementia was associated with significant resource utilization, including preoperative length of stay (LOS), postoperative LOS, intensive care unit LOS, and inflation-adjusted total hospital cost (all P < .0001). Hierarchical modeling demonstrated that dementia was the strongest preoperative predictor for any complication (odds ratio, 8.64; P < .0001) and had the largest risk-adjusted impact on total hospital cost ($22,069; P < .0001). Finally, survival analysis demonstrated that dementia is independently associated with reduced survival after vascular surgery (hazard ratio, 1.37; P = .018).Conclusions: This study demonstrated that dementia is one of the strongest predictors of any complication and increased hospital cost after vascular surgery. Given the high risk of clinical and financial maladies, patients with dementia should be carefully considered and counseled before undergoing vascular surgery.