Factors associated with death 1 year after lower extremity bypass in Northern New England.
Factors associated with death 1 year after lower extremity bypass in Northern New England.
复制标题
新英格兰北部下肢搭桥术后一年死亡的相关因素。
DOI：
10.1016/j.jvs.2009.07.123
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发表时间：
2010
影响因子：
4.3
通讯作者：
J. Cronenwett
中科院分区：
文献类型：
--
作者：
P. Goodney;B. Nolan;A. Schanzer;J. Eldrup;A. Stanley;D. Stone;D. Likosky;J. Cronenwett
在术前决策中使用下肢旁路术（LEB）30天手术死亡率报告可能会低估患者真正从手术中恢复之前的实际死亡率，特别是在老年，虚弱且有明显组织损失的患者中。因此，我们检查术前，患者水平的风险因素，预测生存的第一年内LEB.METHODSUsing我们的区域质量改进计划在北方新英格兰的11家医院，我们研究了2306 LEB程序进行2031例患者之间的2003年1月至2007年12月。60名外科医生为我们的数据库做出了贡献，超过100个人口统计学和临床变量由训练有素的研究人员提取。考克斯比例风险模型被用来产生风险比（HR）和周围的95%置信区间（CI），我们的综合结果测量发生在术后第一年内的死亡率。我们发现，在我们的队列2306旁路手术，11%的患者在手术后1年内死亡（出院前2%，1年随访前9%）。我们在多变量分析中确定了与死亡风险较高相关的6个术前患者特征：充血性心力衰竭（HR 1.3，95% CI 1.0-1.8），糖尿病（HR 1.5，95% CI 1.1-2.1），严重肢体缺血（CLI）（HR 1.7，95% CI 1.3-2.4），缺乏单段隐静脉（HR 1.9，95% CI 1.5-2/5）、年龄超过80岁（HR 2.0，95% CI 1.5-2.7）、透析依赖性（HR 2.7，95% CI 1.9-3.6）和手术的紧急性质（HR 3.4，95% CI 1.7-6.8）。没有危险因素的患者1年死亡率低于5%：有3个或更多危险因素的患者在术后1年内死亡的可能性为28%。当我们比较各中心的风险调整生存率时，我们发现我们地区的一个中心的表现明显好于预期（预测与预期结局比0.7，95%CI 0.6-0.9，P = 0.04）。结论术前风险因素使外科医生能够预测LEB术后第一年的生存率，并更准确地告知患者LEB的手术风险。此外，我们的模型有助于对整个地区的风险调整结果进行基准比较。我们相信，诸如此类的质量改进措施将使外科医生能够确定最佳实践，从而改善各中心LEB的结局。
BACKGROUNDUsing 30-day operative mortality reported with lower extremity bypass (LEB) in preoperative decision making may underestimate the actual death rate encountered before patients have truly recovered from surgery, especially in elderly, debilitated patients with significant tissue loss. Therefore, we examined preoperative, patient-level risk factors that predict survival within the first year following LEB.METHODSUsing our regional quality improvement initiative in 11 hospitals in Northern New England, we studied 2306 LEB procedures performed in 2031 patients between January 2003 and December 2007. Sixty surgeons contributed to our database, and over 100 demographic and clinical variables were abstracted by trained researchers. Cox proportional hazards models were used to generate hazard ratios (HR) and surrounding 95% confidence intervals (CI) for our combined outcome measure of death occurring within the first year postoperatively.RESULTSWe found that within our cohort of 2306 bypass procedures, 11% of patients died within 1 year of surgery (2% prior to discharge, 9% prior to 1-year follow-up). We identified six preoperative patient characteristics associated with higher risk of death in multivariate analysis: congestive heart failure (HR 1.3, 95% CI 1.0-1.8), diabetes (HR 1.5, 95% CI 1.1-2.1), critical limb ischemia (CLI) (HR 1.7, 95% CI 1.3-2.4), lack of single-segment saphenous vein (HR 1.9, 95% CI 1.5-2/5), age over 80 (HR 2.0, 95% CI 1.5-2.7), dialysis dependence (HR 2.7, 95% CI 1.9-3.6), and emergent nature of the procedure (HR 3.4, 95% CI 1.7-6.8). While patients with no risk factors had 1-year death rates that were less than 5%: patients with three or more risk factors had a 28% chance of dying before 1 year postoperatively. When we compared risk-adjusted survival across centers, we found that one center in our region performed significantly better than expected (observed-to-expected outcome ratio 0.7, 95% CI 0.6-0.9, P = .04).CONCLUSIONSPreoperative risk factors allow surgeons to predict survival in the first year following LEB, and to more precisely inform patients about their operative risk with LEB. Additionally, our model facilitates benchmarking comparison of risk-adjusted outcomes across our region. We believe quality improvement measures such as these will allow surgeons to identify best practices and thereby improve outcomes with LEB across centers.