Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery
Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery
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DOI：
10.1001/jamanetworkopen.2019.4330
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发表时间：
2019-05-01
影响因子：
13.8
通讯作者：
Arya, Shipra
中科院分区：
文献类型：
--
作者：
Rothenberg, Kara A.;Stern, Jordan R.;Arya, Shipra
重要性门诊手术在老年人群中越来越普遍。先前的研究已经证明了虚弱和住院患者再入院之间的联系。然而，关于门诊手术后虚弱和再入院之间的关系的数据很少。目的：研究虚弱和择期门诊手术后30天计划外再入院之间的关系，以及手术并发症的潜在介导。和参与者在这项针对国家手术质量改进计划（NSQIP）数据库中2012年和2013年选择性门诊手术的回顾性队列研究中，将417840例接受择期门诊手术的患者分为住院时间（LOS）为0天（LOS = 0）和LOS为1天或1天以上（LOS>= 1）的人群。从2018年6月1日至2019年3月31日进行了统计分析。风险分析指数衡量的暴露脆弱性。主要结局和指标主要结局是30天计划外再入院。结果在本研究的417 840例患者中，59. 2%为女性，2.3%的队列发生了计划外再入院（LOS = 0，2.0%; LOS>= 1，3.4%）。在两个LOS队列中，虚弱患者（平均[SD]年龄，64.9 [15.5]岁）比非虚弱患者（平均[SD]年龄，35.0 [15.8]岁）更有可能发生计划外再入院（LOS = 0，8.3% vs 1.9%; LOS>= 1，8.5% vs 3.2%; P <0.001）。两组患者中，虚弱患者也比非虚弱患者更容易发生并发症（LOS = 0，6.9% vs 2.5%; LOS>= 1，9.8% vs 4.6%; P <0.001）。在多变量分析中，虚弱使计划外再入院的风险加倍（LOS = 0：校正相对风险[RR]，2.1; 95%CI，2.0 - 2.3; LOS>= 1：校正RR，1.8; 95%CI，1.6 - 2.1）。并发症发生率为3.1%，虚弱与并发症风险增加相关（未校正RR，2.6; 95%CI，2.4 - 2.8）。中介分析证实，并发症是虚弱和再入院之间关联的重要中介;然而，它也表明虚弱与再入院的关联仅部分由并发症介导（LOS = 0，22.8%; LOS>= 1，（29.3%）结论和相关性这些研究结果表明，虚弱是择期门诊手术后计划外再入院的一个重要危险因素，独立地和当通过增加的并发症部分介导时。筛查虚弱可能会为干预措施的制定提供信息，以减少计划外再入院，包括门诊手术。
IMPORTANCE Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.OBJECTIVE To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS = 0) and those with a LOS of 1 or more days (LOS >= 1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.EXPOSURE Frailty, as measured by the Risk Analysis Index.MAIN OUTCOMES AND MEASURES The main outcome was 30-day unplanned readmission.RESULTS Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS = 0, 2.0%; LOS >= 1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS = 0, 8.3% vs 1.9%; LOS >= 1, 8.5% vs 3.2%; P < .001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS = 0, 6.9% vs 2.5%; LOS >= 1, 9.8% vs 4.6%; P < .001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS >= 1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS = 0, 22.8%; LOS >= 1, 29.3%).CONCLUSIONS AND RELEVANCE These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.