Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations
Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations
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DOI：
10.1001/jamasurg.2017.4007
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发表时间：
2018-02-01
期刊：
影响因子：
16.9
通讯作者：
Finlayson, Emily
中科院分区：
文献类型：
--
作者：
Seib, Carolyn D.;Rochefort, Holly;Finlayson, Emily
重要性虚弱是一种生理储备减少的指标，与重大择期和急诊普外手术的发病率和死亡率相关，与实际年龄无关。到目前为止，虚弱与门诊普外科手术结果的关系尚未建立。目的：确定接受门诊普外科手术的患者虚弱与围手术期发病率之间的关系。设计，设置，和参与者对2007年至2010年期间140 828例年龄大于40岁的患者进行了回顾性队列研究。2010年美国外科医师学会国家外科质量改进计划参与者使用文件，接受了门诊和23小时住院疝、乳腺、甲状腺或甲状旁腺手术。数据分析时间为2016年8月18日至6月21日，2017.主要结局和指标通过多变量logistic回归和随机效应建模确定国家外科质量改进计划修改的虚弱指数与围手术期发病率之间的关联，以控制当前手术术语代码中的聚类。（80147名女性和60681名男性;平均[SD]年龄，59.3 [12.0]岁）接受了门诊疝（n = 71455）、乳房（n = 51267）、甲状腺或甲状旁腺手术（n = 18106）。在这些患者中，2457例（1/%）发生了任何类型的围手术期并发症，971例（0. 7%）发生了严重围手术期并发症。改良虚弱指数的增加与并发症发生率的逐步增加相关。在调整年龄、性别、人种/种族、麻醉类型、烟草使用、肾衰竭、皮质类固醇使用和当前手术术语代码聚类的多变量分析中，（0.18-0.35，对应2-3个虚弱特征）与1.70的统计学显著优势比相关（95%CI，1.54-1.88; P < .001），严重并发症为2.00（95%CI，1.72-2.34; P < .001）。高改良虚弱指数评分（>= 0.36，对应于>= 4个虚弱特征）与任何并发症的统计学显著优势比3.35（95%CI，2.52-4.46; P <0.001）和严重并发症的3.95（95%CI，2.65-5.87; P <0.001）相关。局部麻醉和监测麻醉护理是唯一与30天严重并发症几率降低相关的可修改协变量，调整后的比值比为0.66（95% CI，0.53-0.81;结论和相关性在普通门诊普外手术中，虚弱与围手术期发病率增加相关，与年龄、麻醉类型、和其他合并症。外科医生在咨询和选择择期门诊手术患者时，应考虑虚弱程度而不是实际年龄。
IMPORTANCE Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.OBJECTIVE To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.MAIN OUTCOMES AND MEASURES The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.RESULTS A total of 140 828 patients (80147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71455), breast (n = 51267), thyroid, or parathyroid surgery (n = 18106). Of these patients, 2457 (1/%) experienced any type of perioperative complication and 971(0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (>= 0.36, corresponding to >= 4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001).CONCLUSIONS AND RELEVANCE Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.