Redefining Multimorbidity in Older Surgical Patients.
Redefining Multimorbidity in Older Surgical Patients.
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重新定义老年外科患者的多重疾病。
DOI：
10.1097/xcs.0000000000000659
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发表时间：
2023
影响因子：
5.2
通讯作者：
Silber,JeffreyH
中科院分区：
文献类型：
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作者：
Ramadan,OmarI;Rosenbaum,PaulR;Reiter,JosephG;Jain,Siddharth;Hill,AlexanderS;Hashemi,Sean;Kelz,RachelR;Fleisher,LeeA;Silber,JeffreyH
背景：外科手术中的多发病是常见的，并且与较差的术后结果相关。然而，传统的多病定义(≥2共病)将绝大多数老年患者标记为多病，限制了临床应用。我们试图基于不同的共病组合来开发和验证更好的外科专业特有的多病定义。STUDY设计：我们对66岁至90岁接受住院普通外科、骨科或血管手术的患者使用医疗保险索赔。使用2016至2017年的数据，我们确定了所有与30天死亡率至少2倍(普通/骨科)或1.5倍(血管)相关的共病组合，与接受相同手术的总人群相比；我们将这些组合称为合格的共病集合。我们将其应用于2018至2019年的数据(普通=230,410名患者，骨科=778,131名患者，血管=146,570名患者)，以获得30天的死亡率估计。结果：与传统的多病定义相比，新定义标记的多病患者要少得多：一般=85.0%(传统)vs55.9%(新)(p<；0.0001)；骨科=66.6%vs40.2%(p<；0.0001)；血管=96.2%vs52.7%(p<；0.0001)。按照新的定义，30天的死亡率更高：普通=3.96%(传统)vs 5.64%(新)(p<；0.0001)；骨科=0.13%vs 1.68%(p<；0.0001)；血管=4.43%vs 7.00%(p<；0.0001)。与所有其他医院相比，资源更好的医院为多病患者和非多病患者提供了显著更大的死亡率收益(普通外科差异=˗0.94%[˗1.36%，˗0.52%]，p<；0.0001；骨科=˗0.20%[˗0.34%，˗0.05%]，p=0.0087；和血管=˗0.12%[˗0.69%，0.45%]，p=0.6795)。结论：与传统定义相比，我们的新多病定义确定了更具体、更高风险的患者池，潜在地帮助临床决策。
BACKGROUND:Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥ 2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.STUDY DESIGN:We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general= 230,410 patients, orthopaedic= 778,131 patients, vascular= 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.RESULTS:Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general= 85.0%(conventional) vs 55.9%(new)(p< 0.0001); orthopaedic= 66.6% vs 40.2%(p< 0.0001); and vascular= 96.2% vs 52.7%(p< 0.0001). Thirty-day mortality was higher by the new definitions: general= 3.96%(conventional) vs 5.64%(new)(p< 0.0001); orthopaedic= 0.13% vs 1.68%(p< 0.0001); and vascular= 4.43% vs 7.00%(p< 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference=˗ 0.94%[˗ 1.36%,˗ 0.52%], p< 0.0001; orthopaedic=˗ 0.20%[˗ 0.34%,˗ 0.05%], p= 0.0087; and vascular=˗ 0.12%[˗ 0.69%, 0.45%], p= 0.6795).CONCLUSIONS:Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.