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Boitano LT, Iannuzzi JC, Tanious A, Mohebali J, Schwartz SI, Chang DC, Clouse WD, Conrad MF. Preoperative Predictors of Discharge Destination after Endovascular Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2019; 57:109-117. [DOI: 10.1016/j.avsg.2018.12.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/21/2018] [Accepted: 12/06/2018] [Indexed: 01/01/2023]
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Preece R, Stenson K, Shaw S, Budge J, Patterson B, Holt P, Loftus I. Recent developments and current controversies in short-stay endovascular aneurysm repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:460-467. [PMID: 30994308 DOI: 10.23736/s0021-9509.19.10952-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Short stay endovascular aneurysm repair pathways (SS-EVAR) provide potential advantages to both healthcare providers and patients. However, these benefits must be carefully balanced against the inherent risks to patient safety and tariff penalties associated with unplanned readmissions. EVIDENCE ACQUISITION A literature review was performed using the databases MEDLINE, Embase and Cochrane Library up until March 2019. Search terms used included "endovascular aneurysm repair," "aneurysm repair," "EVAR," "abdominal aortic aneurysm," "day case," "short stay," "fast track," and "ambulatory." EVIDENCE SYNTHESIS Nine relevant articles (including one prior review on the topic) were identified. This early data suggests that SS-EVAR is associated with good patient satisfaction and modest cost savings for healthcare providers. Patient selection, preoperative preparation and supported discharge with early follow-up are essential components of a SS-EVAR pathway. Increasingly, SS-EVAR tends to be delivered via bilateral percutaneous access and loco-regional anesthesia. Over 70% of patients enrolled onto SS-EVAR pathways successfully complete them. Long procedures with excessive blood loss are associated with pathway non-completion. All serious complications occur within 6 hours of the procedure and the mortality (0-1%), morbidity (8-58%) and readmission rates (0-6%) associated with SS-EVAR remains acceptably low. SS-EVAR pathways can be safely and effectively implemented in both teaching and non-teaching hospitals. CONCLUSIONS Short-stay EVAR pathways are safe and acceptable to patients. With appropriate selection of motivated patients, successful expedited discharge can be achieved with limited readmissions, thus facilitating increased resource efficiency and cost savings for healthcare providers.
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Affiliation(s)
- Ryan Preece
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK -
| | - Katherine Stenson
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK
| | - Sarah Shaw
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK
| | - James Budge
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK
| | - Benjamin Patterson
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK
| | - Peter Holt
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK
| | - Ian Loftus
- St George's Vascular Institute, St George's Hospital, Blackshaw Road, London, UK
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Predicting Postoperative Destination Through Preoperative Evaluation in Elective Open Aortic Aneurysm Repair. J Surg Res 2019; 235:543-550. [DOI: 10.1016/j.jss.2018.10.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/29/2018] [Accepted: 10/25/2018] [Indexed: 12/13/2022]
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Nguyen AT, Nguyen TX, Nguyen TN, Nguyen THT, Pham T, Cumming R, Hilmer SN, Vu HTT. The impact of frailty on prolonged hospitalization and mortality in elderly inpatients in Vietnam: a comparison between the frailty phenotype and the Reported Edmonton Frail Scale. Clin Interv Aging 2019; 14:381-388. [PMID: 30863032 PMCID: PMC6388754 DOI: 10.2147/cia.s189122] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS To investigate the impact of frailty on outcomes in older hospitalized patients, including prolonged length of stay and all-cause mortality 6 months after admission, using both the frailty phenotype and the Reported Edmonton Frail Scale (REFS). PATIENTS AND METHODS This study is the follow-up phase of a study designed to investigate the prevalence of frailty and its impact on adverse outcomes in older hospitalized patients at the National Geriatric Hospital in Hanoi, Vietnam. RESULTS A total of 461 participants were included, with a mean age 76.2±8.9 years, and 56.8% were female. The prevalence of frailty was 31.9% according to the REFS and 35.4% according to Fried's criteria. The kappa coefficient was 0.57 (95% CI =0.49-0.66) between the two frailty criteria in identifying frail and non-frail participants. There was a trend toward increasing the likelihood of prolonged hospitalization in participants with frailty defined by Fried's criteria (adjusted OR =1.49, 95% CI =0.94-2.35) or by REFS (adjusted OR =1.43, 95% CI =0.89-2.29). During 6 months of follow-up, 210 were lost and 18/251 (7.2%) participants died. Mortality was higher in those with frailty defined by either Fried's criteria or REFS. On multivariable survival analysis, adjusted HRs for mortality were 2.65 (95% CI =1.02-6.89) for Fried's criteria and 4.19 (95% CI =1.59-10.99) for REFS. CONCLUSION Fried's frailty phenotype or REFS can be used as a screening tool to detect frailty in older inpatients in Vietnam and predict mortality. Frailty screening can help prioritize targeted frailty-tailored treatments, such as nutrition, early mobility and medication review, for these vulnerable patients to improve clinical outcomes.
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Affiliation(s)
- Anh Trung Nguyen
- The National Geriatric Hospital, Hanoi, Vietnam,
- Department of Geriatrics and Gerontology, Hanoi Medical University, Hanoi, Vietnam,
| | - Thanh Xuan Nguyen
- The National Geriatric Hospital, Hanoi, Vietnam,
- Department of Geriatrics and Gerontology, Hanoi Medical University, Hanoi, Vietnam,
| | - Tu N Nguyen
- The National Geriatric Hospital, Hanoi, Vietnam,
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Thu Hoai Thi Nguyen
- The National Geriatric Hospital, Hanoi, Vietnam,
- Department of Geriatrics and Gerontology, Hanoi Medical University, Hanoi, Vietnam,
- Dinh Tien Hoang Institute of Medicine, Hanoi, Vietnam
| | - Thang Pham
- The National Geriatric Hospital, Hanoi, Vietnam,
- Department of Geriatrics and Gerontology, Hanoi Medical University, Hanoi, Vietnam,
| | - Robert Cumming
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Huyen Thi Thanh Vu
- The National Geriatric Hospital, Hanoi, Vietnam,
- Department of Geriatrics and Gerontology, Hanoi Medical University, Hanoi, Vietnam,
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Richards SJG, Frizelle FA, Geddes JA, Eglinton TW, Hampton MB. Frailty in surgical patients. Int J Colorectal Dis 2018; 33:1657-1666. [PMID: 30218144 DOI: 10.1007/s00384-018-3163-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice. BACKGROUND Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome. METHODS Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases. RESULTS Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients. CONCLUSION Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.
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Affiliation(s)
- Simon J G Richards
- University of Otago, Christchurch, New Zealand. .,Department of Surgery, Christchurch Hospital, Riccarton Ave, Christchurch, New Zealand.
| | - Frank A Frizelle
- University of Otago, Christchurch, New Zealand.,Department of Surgery, Christchurch Hospital, Riccarton Ave, Christchurch, New Zealand
| | | | - Tim W Eglinton
- University of Otago, Christchurch, New Zealand.,Department of Surgery, Christchurch Hospital, Riccarton Ave, Christchurch, New Zealand
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56
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Wang J, Zou Y, Zhao J, Schneider DB, Yang Y, Ma Y, Huang B, Yuan D. The Impact of Frailty on Outcomes of Elderly Patients After Major Vascular Surgery: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2018; 56:591-602. [DOI: 10.1016/j.ejvs.2018.07.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/09/2018] [Indexed: 01/10/2023]
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57
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Juszczak MT, Taib B, Rai J, Iazzolino L, Carroll N, Antoniou GA, Neequaye S, Torella F. Total psoas area predicts medium-term mortality after lower limb revascularization. J Vasc Surg 2018; 68:1114-1125.e1. [DOI: 10.1016/j.jvs.2018.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/16/2018] [Indexed: 01/22/2023]
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58
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Di Capua J, Lugo-Fagundo N, Somani S, Kim JS, Phan K, Lee NJ, Kothari P, Vig KS, Cho SK. Diabetes Mellitus as a Risk Factor for Acute Postoperative Complications Following Elective Adult Spinal Deformity Surgery. Global Spine J 2018; 8:615-621. [PMID: 30202716 PMCID: PMC6125929 DOI: 10.1177/2192568218761361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Diabetes mellitus is a highly prevalent disease in the United States. Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. Considering utilization of spinal surgery will continue to increase, this study investigates the influence of diabetes mellitus on acute postoperative outcomes following elective ASD surgery. METHODS The 2010-2014 American College of Surgeon's National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases (9th Revision) diagnosis codes relevant to ASD surgery. Patients were divided into cohorts based on their diabetic status. Bivariate and multivariate logistic regression analyses were employed to identify which 30-day postoperative outcomes patients are at risk for. RESULTS A total of 5809 patients met the inclusion criteria for the study of which 4553 (84.2%) patients were nondiabetic, 578 (10.7%) patients had non-insulin-dependent diabetes mellitus (NIDDM), and 275 (5.1%) patients had insulin-dependent diabetes mellitus (IDDM). Diabetes status was significantly associated with length of stay ≥5 days (NIDDM: odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.02-1.58, P = .034; IDDM: OR = 1.55, 95% CI = 1.15-2.09, P = .004), any complication (NIDDM: OR = 1.26, 95% CI = 1.01-1.58, P = .037), urinary tract infection (NIDDM: OR = 1.87, 95% CI = 1.14-3.05, P = .012), and cardiac complications (IDDM: OR = 4.05, 95% CI = 1.72-9.51, P = .001). CONCLUSIONS Given the prevalence of diabetes, surgeons will invariably encounter these patients for ASD surgery. The present study identifies the increased risk NIDDM and IDDM patients experience following ASD surgery. Quantification of this increased risk may improve the selection of appropriate surgical candidates, patient risk stratification, and patient postoperative safety.
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Affiliation(s)
- John Di Capua
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1188, New York, NY 10029, USA.
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59
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Singer JP, Diamond JM, Anderson MR, Katz PP, Covinsky K, Oyster M, Blue T, Soong A, Kalman L, Shrestha P, Arcasoy SM, Greenland JR, Shah L, Kukreja J, Blumenthal NP, Easthausen I, Golden JA, McBurnie A, Cantu E, Sonett J, Hays S, Robbins H, Raza K, Bacchetta M, Shah RJ, D’Ovidio F, Venado A, Christie JD, Lederer DJ. Frailty phenotypes and mortality after lung transplantation: A prospective cohort study. Am J Transplant 2018; 18:1995-2004. [PMID: 29667786 PMCID: PMC6105397 DOI: 10.1111/ajt.14873] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/26/2018] [Accepted: 03/31/2018] [Indexed: 01/25/2023]
Abstract
Frailty is associated with increased mortality among lung transplant candidates. We sought to determine the association between frailty, as measured by the Short Physical Performance Battery (SPPB), and mortality after lung transplantation. In a multicenter prospective cohort study of adults who underwent lung transplantation, preoperative frailty was assessed with the SPPB (n = 318) and, in a secondary analysis, the Fried Frailty Phenotype (FFP; n = 299). We tested the association between preoperative frailty and mortality following lung transplantation with propensity score-adjusted Cox models. We calculated postestimation marginalized standardized risks for 1-year mortality by frailty status using multivariate logistic regression. SPPB frailty was associated with an increased risk of both 1- and 4-year mortality (adjusted hazard ratio [aHR]: 7.5; 95% confidence interval [CI]: 1.6-36.0 and aHR 3.8; 95%CI: 1.8-8.0, respectively). Each 1-point worsening in SPPB was associated with a 20% increased risk of death (aHR: 1.20; 95%CI: 1.08-1.33). Frail subjects had an absolute increased risk of death within the first year after transplantation of 12.2% (95%CI: 3.1%-21%). In secondary analyses, FFP frailty was associated with increased risk of death within the first postoperative year (aHR: 3.8; 95%CI: 1.1-13.2) but not over longer follow-up. Preoperative frailty is associated with an increased risk of death after lung transplantation.
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Affiliation(s)
| | - Joshua M. Diamond
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Michaela R. Anderson
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Patricia P. Katz
- Department of Medicine, University of California, San Francisco, CA
| | - Ken Covinsky
- Department of Medicine, University of California, San Francisco, CA
| | - Michelle Oyster
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tatiana Blue
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Allison Soong
- Department of Medicine, University of California, San Francisco, CA
| | - Laurel Kalman
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Pavan Shrestha
- Department of Medicine, University of California, San Francisco, CA
| | - Selim M. Arcasoy
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Lori Shah
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, CA
| | | | - Imaani Easthausen
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Amika McBurnie
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ed Cantu
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Joshua Sonett
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Steven Hays
- Department of Medicine, University of California, San Francisco, CA
| | - Hilary Robbins
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Kashif Raza
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Matthew Bacchetta
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Rupal J. Shah
- Department of Medicine, University of California, San Francisco, CA
| | - Frank D’Ovidio
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Aida Venado
- Department of Medicine, University of California, San Francisco, CA
| | - Jason D. Christie
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - David J. Lederer
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Di Capua J, Somani S, Lugo-Fagundo N, Kim JS, Phan K, Lee NJ, Kothari P, Shin J, Cho SK. Predictors for Non-Home Patient Discharge Following Elective Adult Spinal Deformity Surgery. Global Spine J 2018; 8:266-272. [PMID: 29796375 PMCID: PMC5958482 DOI: 10.1177/2192568217717971] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. The utilization of spinal surgery has increased and this trend is expected to continue. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement and reduce length of stay. METHODS The 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases, Ninth Revision diagnosis codes relevant to ASD. Patients were divided based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and hospital length of stay. RESULTS A total of 4552 patients met inclusion criteria, of which 1102 (24.2%) had non-home discharge. Multivariate regression revealed total relative value unit (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 1.00-1.01); female sex (OR = 1.54, 95% CI = 1.32-1.81); American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander versus black race (OR = 0.52, 95% CI = 0.35-0.78, P = .002); age ≥65 years (OR = 3.72, 95% CI = 3.19-4.35); obesity (OR = 1.18, 95% CI = 1.01-1.38, P = .034); partially/totally functionally dependent (OR = 2.11, 95% CI = 1.49-2.99); osteotomy (OR = 1.42, 95% CI = 1.12-1.80, P = .004) pelvis fixation (OR = 2.38, 95% CI = 1.82-3.11); operation time ≥4 hours (OR = 1.74, 95% CI = 1.47-2.05); recent weight loss (OR = 7.66, 95% CI = 1.52-38.65; P = .014); and American Society of Anesthesiologists class ≥3 (OR = 1.80, 95% CI = 1.53-2.11) as predictors of non-home discharge. P values were <.001 unless otherwise noted. Additionally, multivariate regression found non-home discharge to be a significant variable in prolonged length of stay. CONCLUSIONS The authors suggest these results can be used to inform patients preoperatively of expected discharge destination, anticipate patient discharge needs postoperatively, and reduce health care costs and morbidity associated with prolonged LOS.
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Affiliation(s)
- John Di Capua
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia
- Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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White SJW, Cheung ZB, Ye I, Phan K, Xu J, Dowdell J, Kim JS, Cho SK. Risk Factors for Perioperative Blood Transfusions in Adult Spinal Deformity Surgery. World Neurosurg 2018; 115:e731-e737. [PMID: 29715572 DOI: 10.1016/j.wneu.2018.04.152] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Adult spinal deformity (ASD) surgery is associated with a high rate of perioperative blood transfusions, and it is important to understand the risk factors for perioperative blood transfusions to implement strategies to reduce transfusions. The aim of this study was to identify independent risk factors of perioperative blood transfusions in patients undergoing surgery for ASD. METHODS A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Adult patients undergoing surgery for ASD were separated into 2 cohorts based on whether they received a perioperative blood transfusion. Univariate and multivariate regression models were used to identify risk factors for blood transfusion. RESULTS In our cohort of 5805 patients, 27.1% received a blood transfusion. Multivariate regression analysis showed that patient-specific risk factors were age 65 years or older (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.49-2.03; P < 0.001), American Society of Anesthesiologists classification of 3 or greater (OR, 1.18; 95% CI, 1.01-1.37; P = 0.033), cardiac comorbidity (OR, 1.21; 95% CI, 1.03-1.41; P = 0.018) and bleeding disorder (OR, 2.01; 95% CI, 1.10-3.66; P = 0.023). Surgery-specific risk factors were a posterior approach (OR, 4.25; 95% CI, 3.46-5.22; P < 0.001), pelvic fixation (OR, 1.73; 95% CI, 1.36-2.20; P < 0.001), and osteotomy (OR, 2.08; 95% CI, 1.71-2.51; P < 0.001). Longer operative time was also a risk factor with a duration-dependent effect on the odds of blood transfusion. CONCLUSIONS Recognition of patient- and surgery-specific risk factors for perioperative blood transfusion is important to identify patients who are at high risk and to implement strategies to minimize intraoperative blood loss and decrease healthcare costs.
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Affiliation(s)
- Samuel J W White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ivan Ye
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin Phan
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Xu
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Dowdell
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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62
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Chowdhury MM, Ambler GK, Al Zuhir N, Walker A, Atkins ER, Winterbottom A, Coughlin PA. Morphometric Assessment as a Predictor of Outcome in Older Vascular Surgery Patients. Ann Vasc Surg 2018; 47:90-97. [PMID: 28887259 DOI: 10.1016/j.avsg.2017.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 07/13/2017] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Frailty is a recognized predictor of poor outcome in patients undergoing surgical intervention. Frailty is intricately linked with body morphology, which can be evaluated using morphometric assessment via computerized tomographic (CT) imaging. We aimed to assess the predictive power of such objective assessments in a broad cohort of vascular surgical patients. METHODS A consecutive series of patients aged over 65 years admitted to a vascular unit, who had undergone CT imaging of the abdomen, were analyzed. Demographic and patient-specific data were collated alongside admission relevant information. Outcomes included mortality, length of stay, health care-related costs, and discharge destination. Images were analyzed for 4 morphometric measurements: (1) psoas muscle area, (2) mean psoas density, (3) subcutaneous fat depth, and (4) intra-abdominal fat depth, all taken at the level of the fourth lumbar vertebra. RESULTS Two hundred and ten patients were initially analyzed. Forty-four patients had significant retroperitoneal and abdominal abnormalities that limited appropriate CT analysis. Decreased subcutaneous fat depth was significantly associated with mortality, readmission within 12 months, and increased cost of health care (P < 0.01, adjusted for confounders). Psoas muscle area was significantly associated with readmission-free survival. CONCLUSIONS Morphometric analysis predicts poorer outcome in a broad cohort of vascular surgery patients. Such assessment is likely to enhance patient counseling regarding individual risk as well as enhancing the ability to undertake risk-modified surgical audit.
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Affiliation(s)
- Mohammed M Chowdhury
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graeme K Ambler
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Naail Al Zuhir
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alex Walker
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ellie R Atkins
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Winterbottom
- Department of Interventional Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Kodama A, Koyama A, Sugimoto M, Niimi K, Banno H, Komori K. Association Between Preoperative Frailty and Mortality in Patients With Critical Limb Ischemia Following Infrainguinal Bypass Surgery ― Usefulness of the Barthel Index ―. Circ J 2018; 82:267-274. [DOI: 10.1253/circj.cj-17-0369] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Akio Koyama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Kiyoaki Niimi
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
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Predictors for Patient Discharge Destination After Elective Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2017; 42:1538-1544. [PMID: 28252556 DOI: 10.1097/brs.0000000000002140] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To identify risk factors for nonhome patient discharge after elective anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA ACDF is one of the most performed spinal procedures and this is expected to increase in the coming years. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement applications and subsequently reduce hospital length of stay. METHODS The 2011 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 or 22554. Patients were divided into two cohorts based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and extended hospital length of stay. RESULTS A total of 14,602 patients met the inclusion criteria for the study of which 498 (3.4%) had nonhome discharge. Multivariate logistic regression found that Hispanic versus Black race/ethnicity (odds ratio, OR =0.21, 0.05-0.91, P =0.037), American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander versus Black race/ethnicity (OR = 0.52, 0.34-0.80, p-value = 0.003), White versus Black race/ethnicity (OR = 0.55, 0.42-0.71), elderly age ≥65 years (OR = 3.32, 2.72-4.06), obesity (OR = 0.77, 0.63-0.93, P = 0.008), diabetes (OR = 1.32, 1.06-1.65, P = 0.013), independent versus partially/totally dependent functional status (OR = 0.11, 0.08-0.15), operation time ≥4 hours (OR = 2.46, 1.87-3.25), cardiac comorbidity (OR = 1.38, 1.10-1.72, P = 0.005), and ASA Class ≥3 (OR = 2.57, 2.05-3.20) were predictive factors in patient discharge to a facility other than home. In addition, multivariate logistic regression analysis also found nonhome discharge to be the most predictive variable in prolonged hospital length of stay. CONCLUSION Several predictive factors were identified in patient discharge to a facility other than home, many being preoperative variables. Identification of these factors can expedite patient discharge applications and potentially can reduce hospital stay, thereby reducing the risk of hospital acquired conditions and minimizing health care costs. LEVEL OF EVIDENCE 3.
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Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To identify risk factors for the development of any major complication after elective posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA PLF is one of the most performed fusion techniques with utilization rates increasing by 356% between 1993 and 2001. Surgical and anesthetic advances have made the option of surgery more accessible for elderly patients with a larger comorbidity burden. Identifying risk factors for the development of major complications after elective PLF is important for patient risk stratification and patient safety efforts. METHODS The 2011 to 2014 American College of Surgeon's National Surgical Quality Improvement Program database was queried using Current Procedural Terminology codes 22612, 22630, and 22633. Patients were divided into two cohorts based on the development of any major complication. Bivariate and multivariate logistic regression analyses were employed to identify predictors for the development of ≥ 1, ≥ 2, and ≥ 3 major complications. RESULTS A total of 7761 patients met the inclusion criteria for the study of which, 2055 (26.5%) patients developed one major complication, 249 (3.2%) patients developed two major complications, and 151 (1.9%) patients developed three major complications. The most common complication was intra/postoperative red blood cell transfusion (23.2%). Three multivariate logistic regression models were employed to identify factors associated with ≥ 1, ≥ 2, and ≥ 3 major complications. Patient variables present across all three models were osteotomy, pelvic fixation, operation time ≥4 hours, bleeding disorder, and American Society of Anesthesiology Class ≥ 3. CONCLUSION Several risk factors were identified for the development of major complications after elective PLF. Identification of these factors can improve the selection of appropriate surgical candidates, patient risk stratification, and patient postoperative safety. LEVEL OF EVIDENCE 3.
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Di Capua J, Somani S, Kim JS, Phan K, Lee NJ, Kothari P, Cho SK. Elderly Age as a Risk Factor for 30-Day Postoperative Outcomes Following Elective Anterior Cervical Discectomy and Fusion. Global Spine J 2017; 7:425-431. [PMID: 28811986 PMCID: PMC5544157 DOI: 10.1177/2192568217699383] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal procedures. Considering the high success and low complications rate of ACDF and high prevalence of age-related degeneration of the cervical spine, the rates of ACDF are expected to continually rise. The objective is to identify the association between patient age and 30-day postoperative outcomes following elective ACDF. METHODS The 2010-2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 or 22554. Patients were divided into age quartiles (18-45, 46-52, 53-60, and ≥61 years). Bivariate and multivariate logistic regression analyses were employed to quantify the increased risk of 30-day postoperative complications in the elderly patient population. RESULTS A total of 20 563 patients met the inclusion criteria for the study. The analyses found quartile 4 had an increased odds of length of stay (LOS) ≥5 days (odds ratio [OR] = 2.05, confidence interval [CI ] = 1.62-2.60), pulmonary complications (OR = 3.25, CI = 1.81-5.84), urinary tract infections (UTI) (OR = 2.25, 1.04-4.87, P = .038), cardiac complication (OR = 6.01, CI = 1.36-26.62, P = .018), and sepsis (OR = 4.38, CI = 1.30-14.70, P = .017). Quartiles 2 and 4 had an increased odds of venous thromboembolism (OR = 3.13, CI = 1.14-8.56, P = .026; OR = 3.83, CI = 1.44-10.20, P = .007). Quartiles 3 and 4 experienced an increased odds of unplanned readmission (OR = 1.44, CI = 1.01-2.05, P = .045; OR = 1.88, CI = 1.33-2.66). All P values are <.001 unless otherwise noted. CONCLUSION Elderly patients experienced an increased odds of LOS ≥5 days, pulmonary complications, cardiac compilations, venous thromboembolism, UTI, sepsis, and unplanned readmission. Identification of these factors can improve the selection of appropriate surgical candidates and postoperative safety.
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Affiliation(s)
- John Di Capua
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | | | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1188, New York, NY 10029, USA.
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Frailty in major oncologic surgery of upper gastrointestinal tract: How to improve postoperative outcomes. Eur J Surg Oncol 2017; 43:1566-1571. [DOI: 10.1016/j.ejso.2017.06.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/25/2017] [Accepted: 06/06/2017] [Indexed: 02/07/2023] Open
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Chimukangara M, Helm MC, Frelich MJ, Bosler ME, Rein LE, Szabo A, Gould JC. A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair. Surg Endosc 2017; 31:2509-2519. [PMID: 27699515 PMCID: PMC5378684 DOI: 10.1007/s00464-016-5253-7] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 09/13/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty is a measure of physiologic reserve associated with increased vulnerability to adverse outcomes following surgery in older adults. The 'accumulating deficits' model of frailty has been applied to the NSQIP database, and an 11-item modified frailty index (mFI) has been validated. We developed a condensed 5-item frailty index and used this to assess the relationship between frailty and outcomes in patients undergoing paraesophageal hernia (PEH) repair. METHODS The NSQIP database was queried for ICD-9 and CPT codes associated with PEH repair. Subjects ≥60 years who underwent PEH repair between 2011 and 2013 were included. Five of the 11 mFI items present in the NSQIP data on the most consistent basis were selected for the condensed index. Univariate and multivariate logistic regressions were used to determine the validity of the 5-item mFI as a predictor of postoperative mortality, complications, readmission, and non-routine discharge. RESULTS A total of 3711 patients had data for all variables in the 5-item index, while 885 patients had complete data to calculate the 11-item mFI. After controlling for competing risk factors, including age, ASA score, wound classification, surgical approach, and procedure timing (emergent vs non-emergent), we found the 5-item mFI remained predictive of 30-day mortality and patients being discharged to a location other than home (p < 0.05). A weighted Kappa was calculated to assess agreement between the 5-item and 11-item mFI and was found to be 0.8709 (p < 0.001). CONCLUSIONS Frailty, as assessed by the 5-item mFI, is a reasonable alternative to the 11-item mFI in patients undergoing PEH repair. Utilization of the 5-item mFI allows for a significantly increased sample size compared to the 11-item mFI. Further study is necessary to determine whether the condensed 5-item mFI is a valid measure to assess frailty for other types of surgery.
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Affiliation(s)
- Munyaradzi Chimukangara
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Melissa C Helm
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Matthew J Frelich
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Matthew E Bosler
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Lisa E Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA.
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Ambler GK, Twine CP, Coughlin PA, Boyle JR. Regarding "Description of a risk predictive model of 30-day postoperative mortality after elective abdominal aortic aneurysm repair". J Vasc Surg 2017; 65:1546-1547. [PMID: 28434601 DOI: 10.1016/j.jvs.2016.10.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/25/2016] [Indexed: 10/19/2022]
Affiliation(s)
- Graeme K Ambler
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom; South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, United Kingdom
| | - Christopher P Twine
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom; South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, United Kingdom
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Suskind AM, Walter LC, Zhao S, Finlayson E. Functional Outcomes After Transurethral Resection of the Prostate in Nursing Home Residents. J Am Geriatr Soc 2016; 65:699-703. [PMID: 27918098 DOI: 10.1111/jgs.14665] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To understand outcomes of transurethral resection of the prostate (TURP) or transurethral laser incision of the prostate (TULIP) for the treatment of bladder outlet obstruction in men with high levels of functional dependence, which are poorly understood. DESIGN Retrospective cohort study. SETTING U.S. nursing homes (NHs). PARTICIPANTS Male NH residents aged 65 and older who underwent TURP or TULIP in the United States between 2005 and 2008 (N = 2,869). MEASUREMENTS Changes in activities of daily living (ADLs), Foley catheter status, and survival up to 12 months after surgery were examined. Multivariate regression was used to determine risk of having a Foley catheter 1 year after surgery. RESULTS Sixty-one percent of the cohort had a Foley catheter before the procedure. Of men with a Foley catheter at baseline, 64% had a Foley catheter, 4% had no Foley catheter, and 32% had died by 1-year after the procedure. Having a Foley catheter at baseline (risk ratio (RR) = 1.39, 95% confidence interval (CI) = 1.29-1.50) and poor baseline functional status (RR = 1.34, 95% CI = 1.18-1.52 for individuals in the worst quartile of function) were associated with greater risk of having a Foley catheter at 1-year. CONCLUSION Poor baseline functional status and having a Foley catheter preoperatively were associated with greater risk of TURP or TULIP failure, as measured by the presence of a Foley catheter at 1 year. Preoperative measurement of ADLs may aid in surgical decision-making in this population.
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Affiliation(s)
- Anne M Suskind
- Department of Urology, University of California San Francisco, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Shoujun Zhao
- Department of Urology, University of California San Francisco, San Francisco, California
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco, San Francisco, California
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Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16:157. [PMID: 27580947 PMCID: PMC5007853 DOI: 10.1186/s12877-016-0329-8] [Citation(s) in RCA: 609] [Impact Index Per Article: 76.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/15/2016] [Indexed: 12/12/2022] Open
Abstract
Background As the population ages, increasing numbers of older adults are undergoing surgery. Frailty is prevalent in older adults and may be a better predictor of post-operative morbidity and mortality than chronological age. The aim of this review was to examine the impact of frailty on adverse outcomes in the ‘older old’ and ‘oldest old’ surgical patients. Methods A systematic review was undertaken. Electronic databases from 2010 to 2015 were searched to identify articles which evaluated the relationship between frailty and post-operative outcomes in surgical populations with a mean age of 75 and older. Articles were excluded if they were in non-English languages or if frailty was measured using a single marker only. Demographic data, type of surgery performed, frailty measure and impact of frailty on adverse outcomes were extracted from the selected studies. Quality of the studies and risk of bias was assessed by the Epidemiological Appraisal Instrument. Results Twenty-three studies were selected for the review and they were assessed as medium to high quality. The mean age ranged from 75 to 87 years, and included patients undergoing cardiac, oncological, general, vascular and hip fracture surgeries. There were 21 different instruments used to measure frailty. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results and study quality was for associations between frailty and increased mortality at 30 days, 90 days and one year follow-up, post-operative complications and length of stay. A small number of studies reported on discharge to institutional care, functional decline and lower quality of life after surgery, and also found a significant association with frailty. Conclusion There was strong evidence that frailty in older-old and oldest-old surgical patients predicts post-operative mortality, complications, and prolonged length of stay. Frailty assessment may be a valuable tool in peri-operative assessment. It is possible that different frailty tools are best suited for different acuity and type of surgical patients. The association between frailty and return to pre-morbid function, discharge destination, and quality of life after surgery warrants further research.
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Affiliation(s)
- Hui-Shan Lin
- Centre for Research in Geriatric Medicine, Princess Alexandra Hospital, The University of Queensland, Level 2, Building 33, Ipswich Road, Woolloongabba, QLD, 4102, Australia.
| | - J N Watts
- Centre for Research in Geriatric Medicine, Princess Alexandra Hospital, The University of Queensland, Level 2, Building 33, Ipswich Road, Woolloongabba, QLD, 4102, Australia
| | - N M Peel
- Centre for Research in Geriatric Medicine, Princess Alexandra Hospital, The University of Queensland, Level 2, Building 33, Ipswich Road, Woolloongabba, QLD, 4102, Australia
| | - R E Hubbard
- Centre for Research in Geriatric Medicine, Princess Alexandra Hospital, The University of Queensland, Level 2, Building 33, Ipswich Road, Woolloongabba, QLD, 4102, Australia
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Zhou H, Della PR, Roberts P, Goh L, Dhaliwal SS. Utility of models to predict 28-day or 30-day unplanned hospital readmissions: an updated systematic review. BMJ Open 2016; 6:e011060. [PMID: 27354072 PMCID: PMC4932323 DOI: 10.1136/bmjopen-2016-011060] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To update previous systematic review of predictive models for 28-day or 30-day unplanned hospital readmissions. DESIGN Systematic review. SETTING/DATA SOURCE CINAHL, Embase, MEDLINE from 2011 to 2015. PARTICIPANTS All studies of 28-day and 30-day readmission predictive model. OUTCOME MEASURES Characteristics of the included studies, performance of the identified predictive models and key predictive variables included in the models. RESULTS Of 7310 records, a total of 60 studies with 73 unique predictive models met the inclusion criteria. The utilisation outcome of the models included all-cause readmissions, cardiovascular disease including pneumonia, medical conditions, surgical conditions and mental health condition-related readmissions. Overall, a wide-range C-statistic was reported in 56/60 studies (0.21-0.88). 11 of 13 predictive models for medical condition-related readmissions were found to have consistent moderate discrimination ability (C-statistic ≥0.7). Only two models were designed for the potentially preventable/avoidable readmissions and had C-statistic >0.8. The variables 'comorbidities', 'length of stay' and 'previous admissions' were frequently cited across 73 models. The variables 'laboratory tests' and 'medication' had more weight in the models for cardiovascular disease and medical condition-related readmissions. CONCLUSIONS The predictive models which focused on general medical condition-related unplanned hospital readmissions reported moderate discriminative ability. Two models for potentially preventable/avoidable readmissions showed high discriminative ability. This updated systematic review, however, found inconsistent performance across the included unique 73 risk predictive models. It is critical to define clearly the utilisation outcomes and the type of accessible data source before the selection of the predictive model. Rigorous validation of the predictive models with moderate-to-high discriminative ability is essential, especially for the two models for the potentially preventable/avoidable readmissions. Given the limited available evidence, the development of a predictive model specifically for paediatric 28-day all-cause, unplanned hospital readmissions is a high priority.
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Affiliation(s)
- Huaqiong Zhou
- Clinical Nurse, General Surgical Ward, Princess Margaret Hospital for Children, Perth, Western Australia, Australia School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Phillip R Della
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Pamela Roberts
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Louise Goh
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Satvinder S Dhaliwal
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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The Impact of Frailty on Mortality, Length of Stay and Re-hospitalisation in Older Patients with Atrial Fibrillation. Heart Lung Circ 2016; 25:551-7. [DOI: 10.1016/j.hlc.2015.12.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/09/2015] [Accepted: 12/06/2015] [Indexed: 01/08/2023]
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McRae PJ, Walker PJ, Peel NM, Hobson D, Parsonson F, Donovan P, Reade MC, Marquart L, Mudge AM. Frailty and Geriatric Syndromes in Vascular Surgical Ward Patients. Ann Vasc Surg 2016; 35:9-18. [PMID: 27238988 DOI: 10.1016/j.avsg.2016.01.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Preoperative frailty is an important predictor of poor outcomes but the relationship between frailty and geriatric syndromes is less clear. The aims of this study were to describe the prevalence of frailty and incidence of geriatric syndromes in a cohort of older vascular surgical ward patients, and investigate the association of frailty and other key risk factors with the occurrence of one or more geriatric syndromes (delirium, functional decline, falls, and/or pressure ulcers) and two hospital outcomes (acute length of stay and discharge destination). METHODS This prospective cohort study was conducted in a vascular surgical ward in a tertiary teaching hospital in Brisbane, Australia. Consecutive patients aged ≥65 years, admitted for ≥72 hr, were eligible for inclusion. Frailty was defined as one or more of functional dependency, cognitive impairment, or nutritional impairment at admission. Delirium was identified using the Confusion Assessment Method and a validated chart extraction tool. Functional decline from admission to discharge was identified from daily nursing documentation of activities of daily living. Falls were identified according to documentation in the medical record cross-checked with the incident reporting system. Pressure ulcers, acute length of stay, and discharge destination were identified by documentation in the medical record. Risk factors associated with geriatric syndromes, acute length of stay, and discharge destination were assessed using multivariable logistic regression models. RESULTS Of 110 participants, 43 (39%) patients were frail and geriatric syndromes occurred in 40 (36%). Functional decline occurred in 25% of participants, followed by delirium (20%), pressure ulcers (12%), and falls (4%). In multivariable logistic analysis, frailty [odds ratio (OR) 6.7, 95% confidence interval (CI) 2.0-22.1, P = 0.002], nonelective admission (OR 7.2, 95% CI 2.2-25.3, P = 0.002), higher physiological severity (OR 5.5, 95% CI 1.1-26.8, P = 0.03), and operative severity (OR 4.6, 95% CI 1.2-17.7, P = 0.03) increased the likelihood of any geriatric syndrome. Frailty was an important predictor of longer length of stay (OR 2.6, 95% CI 1.0-6.8, P = 0.06) and discharge destination (OR 4.2, 95% CI 1.2-13.8, P = 0.02). Nonelective admission significantly increased the likelihood of discharge to a higher level of care (OR 5.3, 95% CI 1.3-21.6, P = 0.02). CONCLUSIONS Frailty and geriatric syndromes were common in elderly vascular surgical ward patients. Frail patients and nonelective admissions were more likely to develop geriatric syndromes, have a longer length of stay, and be discharged to a higher level of care.
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Affiliation(s)
- Prudence J McRae
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland School of Medicine, Brisbane, Queensland, Australia.
| | - Philip J Walker
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland School of Medicine, Discipline of Surgery and Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Nancye M Peel
- The University of Queensland School of Medicine, Centre for Research in Geriatric Medicine, Brisbane, Queensland, Australia
| | - Denise Hobson
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland School of Medicine, Brisbane, Queensland, Australia
| | - Fiona Parsonson
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Peter Donovan
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland School of Medicine, Brisbane, Queensland, Australia
| | - Michael C Reade
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland School of Medicine, Burns, Trauma and Critical Care Research Centre, Brisbane, Queensland, Australia
| | - Louise Marquart
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Alison M Mudge
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland School of Medicine, Brisbane, Queensland, Australia; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
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Abstract
Anemia and frailty are two common findings in geriatric patients and have been shown to be associated with poor outcomes in this patient group. Recent studies have contributed to the growing evidence of a possible association with the age-related chronic inflammatory status known as “inflammaging”. These findings do not only give a better insight into the pathogenesis of anemia in frailty, but also offer new treatment options. The present article focuses on this assumed association between anemia, frailty, and inflammaging and summarizes current management options for anemia in frail patients.
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Affiliation(s)
- Gabriele Röhrig
- Ageing Clinical Research, Department II of Internal Medicine, University Hospital Cologne, Cologne, Germany; Department of Geriatrics, St Marien Hospital Cologne, Cologne, Germany
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Chimukangara M, Frelich MJ, Bosler ME, Rein LE, Szabo A, Gould JC. The impact of frailty on outcomes of paraesophageal hernia repair. J Surg Res 2016; 202:259-66. [PMID: 27229099 DOI: 10.1016/j.jss.2016.02.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 02/07/2016] [Accepted: 02/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Frailty is a measure of physiological reserve that has been used to predict outcomes after surgical procedures in the elderly. We hypothesized that frailty would be associated with outcomes after paraesophageal hernia (PEH) repair. METHODS The National Surgical Quality Improvement Program database (2011-2013) was queried for International Classification of Diseases, Version 9 and Current Procedural Terminology codes associated with PEH repair in patients aged ≥ 60 y. A previously described modified frailty index (mFI), based on 11 clinical variables in National Surgical Quality Improvement Program was used to quantify frailty. Multivariate logistic regression was used to determine the relationship between frailty, complications, and mortality. RESULTS Of the 4434 PEH repairs that met inclusion criteria, 885 records were included in the final analysis (20%). Excluded patients were missing one or more variables in the mFI. The rate of complications that were Clavien-Dindo Grade ≥ 3 was 6.1%. Mortality was 0.9%. The readmission rate was 8.2%, and 10.9% of patients were discharged to a facility other than home. Relative to mFI scores of 0, 1, 2, and ≥3, the respective occurrence percentages were as follows; Grade ≥3 complication: 3.2%, 4.7%, 9.8%, and 23.3% (P < 0.0001; odds ratio [OR] 3.51; confidence interval [CI] 1.46-8.46); mortality: 0.0%, 0.9%, 1.8%, and 2.3% (P = 0.0974); discharge to facility other than home: 4.4%, 10.9%, 15.7%, and 31.7% (P < 0.0001; OR 4.07; CI 1.29-12.82); and readmission: 8.9%, 6.8%, 8.5%, and 16.3% (P = 0.1703; OR 1.01; CI 0.36-2.84). Complications and discharge destination were significantly correlated with the mFI. CONCLUSIONS Frailty, as assessed by the mFI, is correlated with postoperative complications and discharge to a facility other than home after PEH repair.
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Affiliation(s)
- Munyaradzi Chimukangara
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew J Frelich
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew E Bosler
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa E Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Puts MTE, Toubasi S, Atkinson E, Ayala AP, Andrew M, Ashe MC, Bergman H, Ploeg J, McGilton KS. Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a protocol for a scoping review of the literature and international policies. BMJ Open 2016; 6:e010959. [PMID: 26936911 PMCID: PMC4785293 DOI: 10.1136/bmjopen-2015-010959] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/11/2016] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION With ageing comes increased vulnerability such that older adults' ability to recover from acute illnesses, fall-related injuries and other stresses related to the physical ageing processes declines. This increased vulnerability, also known as frailty, is common in older adults and associated with increased healthcare service use and adverse health outcomes. Currently, there is no overview of available interventions to prevent or reduce the level of frailty (as defined by study's authors) which will help healthcare providers in community settings caring for older adults. We will address this gap by reviewing interventions and international policies that are designed to prevent or reduce the level of frailty in community-dwelling older adults. METHODS AND ANALYSIS We will conduct a scoping review using the updated guidelines of Arksey and O'Malley to systematically search the peer-reviewed journal articles to identify interventions that aimed to prevent or reduce the level of frailty. We will search grey literature for international policies. The 6-stage scoping review model involves: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results and (6) consulting with key stakeholders. ETHICS AND DISSEMINATION Our scoping review will use robust methodology to search for available interventions focused on preventing or reducing the level of frailty in community-dwelling older adults. We will consult with stakeholders to find out whether they find the frailty interventions/policies useful and to identify the barriers and facilitators to their implementation in Canada. We will disseminate our findings to relevant stakeholders at local, national and international levels by presenting at relevant meetings and publishing the findings. Our review will identify gaps in research and provide healthcare providers and policymakers with an overview of interventions that can be implemented to prevent or postpone frailty.
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Affiliation(s)
- Martine T E Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Samar Toubasi
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Esther Atkinson
- Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada
| | - Ana Patricia Ayala
- Gerstein Information Science Centre, University of Toronto Libraries, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Andrew
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Maureen C Ashe
- Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Howard Bergman
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Jenny Ploeg
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Katherine S McGilton
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Srinivasan A, Ambler GK, Hayes PD, Chowdhury MM, Ashcroft S, Boyle JR, Coughlin PA. Premorbid function, comorbidity, and frailty predict outcomes after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2016; 63:603-9. [DOI: 10.1016/j.jvs.2015.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/02/2015] [Indexed: 01/04/2023]
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Suskind AM, Walter LC, Jin C, Boscardin J, Sen S, Cooperberg MR, Finlayson E. Impact of frailty on complications in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database. BJU Int 2016; 117:836-42. [PMID: 26691588 DOI: 10.1111/bju.13399] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the association of frailty, a measure of diminished physiological reserve, with both major and minor surgical complications among patients undergoing urological surgery. MATERIALS AND METHODS Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2007 to 2013, we identified all urological cases that appeared > 1000 times in the dataset among patients aged ≥40 years. Frailty was measured using the NSQIP frailty index (FI), a validated measure that includes 11 impairments, such as decreased functional status and impaired sensorium. We created multivariable logistic regression models using the NSQIP FI to assess major and minor complications after surgery. RESULTS We identified 95 108 urological cases representing 21 urological procedures. The average frequency of complications per individual was 11.7%, with the most common complications being hospital readmission (6.2%), blood transfusion (4.6%) and urinary tract infection (3.1%). Major and minor complications increased with increasing NSQIP FI. Frailty remained strongly associated with complications after adjustment for year, age, race, smoking status and method of anaesthesia (adjusted odds ratio 1.74 [95% confidence interval 1.64, 1.85] for an NSQIP FI ≥0.18). Increasing NSQIP FI was associated with increasing frequency of complications within age groups (by decade) up to age 81 years and across most procedures. CONCLUSION Frailty strongly correlates with risk of postoperative complications among patients undergoing urological surgery. This finding is true within most age groups and across most urological procedures.
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Affiliation(s)
- Anne M Suskind
- Department of Urology, University of California, San Francisco, CA, USA
| | - Louise C Walter
- Division of Geriatrics, VA Medical Center, University of California, San Francisco, CA, USA
| | - Chengshi Jin
- Division of Geriatrics, VA Medical Center, University of California, San Francisco, CA, USA
| | - John Boscardin
- Departments of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Saunak Sen
- Departments of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Emily Finlayson
- Division of Geriatrics, VA Medical Center, University of California, San Francisco, CA, USA.,Department of Surgery, Division of General Surgery, University of California, San Francisco, CA, USA
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81
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Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation. Ann Vasc Surg 2015; 31:124-33. [PMID: 26616501 DOI: 10.1016/j.avsg.2015.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 07/31/2015] [Accepted: 08/22/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The above-knee amputation (AKA) is an operation of last resort with high postoperative morbidity and mortality. This study identifies preoperative risk factors predictive of both 30-day mortality and extended length of stay (LOS) in AKA patients. METHODS Two hundred ninety-five AKA patients from 2004 to 2013 from a single institution were retrospectively reviewed using a deidentified electronic medical record. Rationally selected factors potentially influencing 30-day mortality and LOS were chosen, including demographics, etiologies, vascular surgical history, lifestyle factors, comorbidities, and laboratory values. Variables trending with one of the end points on bivariate analysis (P ≤ 0.10) were entered into multivariate forward stepwise regression models to determine independence as a risk factor (P ≤ 0.05). Subgroup analysis of AKA patients without a traumatic, burn, or malignant etiology was similarly conducted. RESULTS Within the 295 patient cohort, 60% of the patients were male, 18% were African American, mean age was 58 years and mean body mass index was 28 kg/m(2). The 30-day mortality rate was 9%, and mean postoperative LOS of discharged patients was 9.3 days. Upon logistic regression, thrombocytopenia (platelet count < 250 × 10(6)/mL, P < 0.001, odds ratio 6.1) and preoperative septic shock (P = 0.02, odds ratio 5.1) were identified as independent risk factors for 30-day mortality. Upon linear regression, burn etiology (P < 0.001, B = 15.8 days), leukocytosis (white blood cell count > 12 × 10(6)/mL, P < 0.001, B = 6.2 days), and guillotine amputation (P < 0.001, B = 7.6 days) were independently associated with prolonged LOS. Excluding patients with AKAs due to trauma, burn, or malignancy, only thrombocytopenia (platelet count < 250 × 10(6)/mL, P < 0.001, odds ratio 10.2) and leukocytosis (white blood cell count > 12 × 10(6)/mL, P = 0.01, B = 5.2 days) were independent risk factors for in-hospital mortality and prolonged LOS, respectively. CONCLUSIONS Preoperative septic shock and thrombocytopenia are independent risk factors for 30-day mortality after AKA, while burn etiology, leukocytosis, and guillotine amputation contribute to prolonged LOS. Awareness of these risk factors may help enhance both preoperative decision making and expectations of the hospital admission.
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82
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Kraiss LW, Beckstrom JL, Brooke BS. Frailty assessment in vascular surgery and its utility in preoperative decision making. Semin Vasc Surg 2015; 28:141-7. [PMID: 26655058 DOI: 10.1053/j.semvascsurg.2015.10.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The average patient requiring vascular surgery has become older, as life expectancy within the US population has increased. Many older patients have some degree of frailty and reside near the limit of their physiological reserve with restricted ability to respond to stressors such as surgery. Frailty assessment is an important part of the preoperative decision-making process, in order to determine whether patients are fit enough to survive the vascular surgery procedure and live long enough to benefit from the intervention. In this review, we will discuss different measures of frailty assessment and how they can be used by vascular surgery providers to improve preoperative decision making and the quality of patient care.
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Affiliation(s)
- Larry W Kraiss
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132.
| | - Julie L Beckstrom
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132
| | - Benjamin S Brooke
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132
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