Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions
Mortality and Health Care Utilization Among Medicare Patients Undergoing Emergency General Surgery vs Those With Acute Medical Conditions
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DOI：
10.1001/jamasurg.2019.5087
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发表时间：
2020-03-01
期刊：
影响因子：
16.9
通讯作者：
Cooper, Zara
中科院分区：
文献类型：
--
作者：
Lee, Katherine C.;Sturgeon, Daniel;Cooper, Zara
急诊普外科（EGS）占住院患者的11%，其中近一半是老年人。老年人在EGS后死亡率和再入院率较高，但这些结果与急性医疗状况相比如何，这是质量改进的目标，目前还知之甚少。目的研究接受EGS的医疗保险受益人与急性医疗状况患者相比，是否经历了类似的1年结果。设计，设置和参与者一项回顾性队列研究使用了2008年1月1日至2014年12月31日的Medicare索赔数据，纳入了65岁或以上的成年人，他们至少有1年的Medicare索赔，因5种最高负担的EGS手术之一而紧急入院（部分结肠切除术、小肠切除术、消化性溃疡病手术、粘连松解术或剖腹手术）或急性医学状况（肺炎、心力衰竭或急性心肌梗死）的初步诊断。在2步算法中，将接受EGS的患者和患有急性医学疾病的患者1：1匹配：（1）按医院精确匹配或（2）与年龄、性别、人种/种族、Charlson合并症指数、个体合并症、基于索赔的虚弱指数、入院年份和任何重症监护病房住院时间匹配的倾向评分。数据分析的时间为2018年7月16日至2019年11月13日。暴露部分结肠切除术、小肠切除术、消化性溃疡手术、粘连松解术或剖腹手术或初步诊断为肺炎、心力衰竭或急性心肌梗死。主要结局和指标1年死亡率、出院后医疗服务利用（急诊就诊、额外住院、重症监护室住院或总住院次数）和1年内在家天数。（平均[SD]年龄，78.9 [7.8]岁; 272 482 [56.6%]女性），具有充分的协变量平衡。与内科患者相比，接受EGS的患者30天死亡率较高（60 683 [12.6%] vs 56 713 [11.8%]，P <0.001），但1年死亡率较低（142 846 [29.7%] vs 158 385 [32.9%]，P <0.001）。在409363对出院后幸存的患者中，内科患者在出院后一年内的总医院就诊率较高（4 vs 3/人年;发生率比，1.31; 95% CI，1.30-1.32），但与接受EGS的患者相比，平均在家天数相似（293 vs 309天;发病率比，1.004; 95%CI，1.004-1.004）。结论和相关性在这项研究中，接受EGS的老年患者与急性内科疾病患者一样，具有同样高的1年死亡率、住院率和离家天数。这些研究结果表明，EGS也应该有针对性的国家质量改进计划。
Importance Emergency general surgery (EGS) represents 11% of hospitalizations, and almost half of these hospitalized patients are older adults. Older adults have high rates of mortality and readmissions after EGS, yet little is known as to how these outcomes compare with acute medical conditions that have been targets for quality improvement.Objective To examine whether Medicare beneficiaries who undergo EGS experience similar 1-year outcomes compared with patients admitted with acute medical conditions.Design, Setting, and Participants This population-based, retrospective cohort study using Medicare claims data from January 1, 2008, to December 31, 2014, included adults 65 years or older with at least 1 year of Medicare claims who had urgent or emergency admissions for 1 of the 5 highest-burden EGS procedures (partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy) or a primary diagnosis of an acute medical condition (pneumonia, heart failure, or acute myocardial infarction). Patients undergoing EGS and those with acute medical conditions were matched 1:1 in a 2-step algorithm: (1) exact match by hospital or (2) propensity score match with age, sex, race/ethnicity, Charlson Comorbidity Index, individual comorbid conditions, claims-based frailty index, year of admission, and any intensive care unit stay. Data analysis was performed from July 16, 2018, to November 13, 2019.Exposures Partial colectomy, small-bowel resection, peptic ulcer disease surgery, lysis of adhesions, or laparotomy or a primary diagnosis pneumonia, heart failure, or acute myocardial infarction.Main Outcomes and Measures One-year mortality, postdischarge health care utilization (emergency department visit, additional hospitalization, intensive care unit stay, or total hospital encounters), and days at home during 1 year.Results A total of 481 417 matched pairs (mean [SD] age, 78.9 [7.8] years; 272 482 [56.6%] female) with adequate covariate balance were included in the study. Patients undergoing EGS experienced higher 30-day mortality (60 683 [12.6%] vs 56 713 [11.8%], P < .001) yet lower 1-year mortality (142 846 [29.7%] vs 158 385 [32.9%], P < .001) compared with medical patients. Among 409 363 pairs who survived discharge, medical patients experienced higher rates of total hospital encounters in the year after discharge (4 vs 3 per person-year; incidence rate ratio, 1.31; 95% CI, 1.30-1.32) but had similar mean days at home compared with patients undergoing EGS (293 vs 309 days; incident rate ratio, 1.004; 95% CI, 1.004-1.004).Conclusions and Relevance In this study, older patients undergoing EGS had similarly high 1-year rates of mortality, hospital use, and days away from home as acutely ill medical patients. These findings suggest that EGS should also be targeted for national quality improvement programs.