Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.
Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.
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DOI：
10.1213/ane.0000000000003671
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发表时间：
2019-03
影响因子：
5.7
通讯作者：
Frank SM
中科院分区：
文献类型：
--
作者：
Cho BC;DeMario VM;Grant MC;Hensley NB;Brown CH 4th;Hebbar S;Mandal K;Whitman GJ;Frank SM
大型随机试验支持的限制性输血策略正在导致心脏手术中血液利用率的下降。然而，仍有待确定的是，较低的出院血红蛋白(Hb)水平对再入院率的影响。我们评估了出院时Hb水平较高和较低的患者，以比较冠状动脉旁路移植术(CABG)后30天的再住院率。我们回顾评估了从2013年1月到2016年5月在我们机构接受单独冠状动脉搭桥术的1552名患者。我们评估了两组Hb：“高”(上)和“低”(下)，平均出院Hb水平为9.4g/dL，比较患者特征、血液利用率和临床结果，包括30天再住院率。我们根据出院Hb水平将患者分为4组：“无贫血”(>；12 g/dL)、“轻度贫血”(10-11.9 g/dL)、“中度贫血”(8-9.9 g/dL)和“重度贫血”(<；8 g/dL)，进一步评估最低出院Hb水平对30天再住院率的影响。风险调整考虑了年龄、性别、Charlson合并症指数、术前合并症、胸骨翻修术和患者血液管理计划的实施。除Hb水平外，“高”组和“低”组的患者特征相似(平均出院Hb分别为10.4±0.9g/dL和8.5±0.6g/dL)。值得注意的是，在“高”组(76/746；10.2%)和“低”组(97/806；12.0%)之间，没有证据表明30天再住院率存在差异(P=0.25)。这4组贫血患者在年龄、胸骨翻修手术发生率、Hb水平、某些患者的合并症和再入院时间等方面存在差异。在多变量分析中，与“高”Hb组相比，“低”Hb组再入院的风险调整后的几率(优势比，1.16；95%可信区间，0.84-1.61；P=.36)并不显著。与出院Hb≥为8g/dL的患者相比，Hb<；8g/dL患者的再住院率更高(22/129；17.1%vs151/1423；10.6%；P=0.036)。在多变量分析中，出院时Hb<；8g/dL是再入院的预测因素(优势比1.77；95%可信区间1.05-2.88；P=0.03)。再次入院的最常见原因是容量超负荷，其次是感染和心律失常。对于CABG患者，出院时Hb水平低于机构平均值并不能提供与增加的30天再住院率相关的证据。在少数Hb<；8g/dL出院的患者中，有迹象表明再次入院的风险增加，需要更大规模的更多对照研究来验证或驳斥这一发现。
Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels on discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG). We retrospectively evaluated 1552 patients undergoing isolated CABG at our institution from January 2013 to May 2016. We evaluated 2 Hb cohorts: “high” (above) and “low” (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (<8 g/dL) discharge Hb levels on 30-day readmission rates by dividing the patients into 4 anemia cohorts based on discharge Hb levels: “no anemia” (>12 g/dL), “mild anemia” (10–11.9 g/dL), “moderate anemia” (8–9.9 g/dL), and “severe anemia” (<8 g/dL). Risk adjustment accounted for age, sex, Charlson comorbidity index, preoperative comorbidities, revision sternotomy, and patient blood management program implementation. The “high” and “low” groups had similar patient characteristics except for Hb levels (mean discharge Hb was 10.4 ± 0.9 vs 8.5 ± 0.6 g/dL, respectively). Notably, no evidence for a difference in 30-day readmission rates was noted between the “high” (76/746; 10.2%) and “low” (97/806; 12.0%) (P = .25) Hb cohorts. The 4 anemia cohorts had differences in age, revision sternotomy incidence, Hb levels, certain patient comorbidities, and time to readmission. On multivariable analysis, the risk-adjusted odds of readmission in the “low” Hb cohort (odds ratio, 1.16; 95% confidence interval, 0.84–1.61; P = .36) was not significant compared to the “high” Hb cohort. Compared to patients with discharge Hb ≥8 g/dL, patients with Hb <8 g/dL had a higher incidence of readmission (22/129; 17.1% vs 151/1423; 10.6%; P = .036). On multivariable analysis, Hb <8 g/dL on discharge was predictive of readmission (odds ratio, 1.77; 95% confidence interval, 1.05–2.88; P = .03). The most common reason for readmission was volume overload, followed by infection and arrhythmias. A discharge Hb level below the institution mean for CABG patients does not provide evidence for an association with an increased 30-day readmission rate. In the small number of patients discharged with Hb <8 g/dL, there is a suggestion of increased risk for readmission and larger more controlled studies are needed to verify or refute this finding.