1
|
Jehan FS, Alizai Q, Powers MT, Khreiss M, Joseph B, Aziz H. Feeble, fallen, and forgetting: association of cognitive impairment and falls on outcomes of major intra-abdominal surgeries in older adults. J Gastrointest Surg 2024:S1091-255X(24)00525-0. [PMID: 38964533 DOI: 10.1016/j.gassur.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/03/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Both cognitive impairment/dementia (CID) and falls occur more commonly in older adults than in younger patients. This study aimed to analyze the association of a history of CID or falls with the postoperative outcomes of older adults undergoing major intra-abdominal surgeries on a national level. METHODS We retrospectively analyzed the American College of Surgeons-National Surgical Quality Improvement Program 2022 Participant Use Data File. Our primary outcome was postoperative mortality. Statistical analysis was performed using the Chi-square test and multivariate regression analysis. RESULTS On multivariable regression analyses, a history of both CID (odds ratio [OR] = 1.9; CI: 1.5-2.5; P < .01) and a fall (OR = 1.8; CI: 1.4-2.3; P < .01) were independently associated with higher adjusted odds of mortality. History of CID or falls was also a predictor of overall complications, major complications, and discharge to a care facility. CONCLUSION A history of CID or falls in older adults before major intra-abdominal surgeries was associated with a high risk of postoperative mortality and morbidity. Further studies are required to establish the causal relation of these factors and the steps to mitigate the risk of associated adverse outcomes.
Collapse
Affiliation(s)
- Faisal S Jehan
- Department of Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Qaider Alizai
- Department of Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Mary T Powers
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Mohammad Khreiss
- Department of Surgery, Univerisity of Arizona College of Medicine, Tucson, AZ, United States
| | - Bellal Joseph
- Department of Surgery, Univerisity of Arizona College of Medicine, Tucson, AZ, United States
| | - Hassan Aziz
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States.
| |
Collapse
|
2
|
James AL, Lattimore CM, Cramer CL, Mubang ET, Turrentine FE, Zaydfudim VM. The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108509. [PMID: 38959846 DOI: 10.1016/j.ejso.2024.108509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/11/2024] [Accepted: 06/23/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. STUDY DESIGN This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65-74, 75-84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. RESULTS 577 patients were included: 62.6 % were 65-74 years old, 31.7 % 75-84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. CONCLUSION Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.
Collapse
Affiliation(s)
- Amber L James
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Courtney M Lattimore
- University of Virginia School of Medicine, Charlottesville, VA, USA; Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Christopher L Cramer
- University of Virginia School of Medicine, Charlottesville, VA, USA; Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Eric T Mubang
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Florence E Turrentine
- University of Virginia School of Medicine, Charlottesville, VA, USA; Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA.
| |
Collapse
|
3
|
Kassahun WT, Babel J, Mehdorn M. The impact of chronic obstructive pulmonary disease on surgical outcomes after surgery for an acute abdominal diagnosis. Eur J Trauma Emerg Surg 2024; 50:799-808. [PMID: 38062271 PMCID: PMC11249436 DOI: 10.1007/s00068-023-02399-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/02/2023] [Indexed: 07/16/2024]
Abstract
PURPOSE The current study was undertaken to describe the independent contribution of chronic obstructive pulmonary disease (COPD) to the risk of postoperative morbidity and in-hospital mortality among patients undergoing surgery for an acute abdominal diagnosis. METHODS Patients who underwent emergency abdominal procedures were identified from the electronic database of the Department of Visceral, Transplantation, Thoracic and Vascular Surgery of our institution. To evaluate differences in surgical risk associated with COPD, patients with COPD were matched for age, sex, and type of surgery with an equal number of controls who did not have COPD. Logistic regression was performed to evaluate the univariate and multivariate associations between the independent variables, including COPD and outcome variables. RESULTS Between January 2012 and December 2022, 3519 patients undergoing abdominal emergency surgery were identified in our abdominal surgical department. After removing ineligible cases, 201 COPD cases with an equal number of matched controls remained for analysis. The prevalence of COPD after the exclusion of ineligible cases was 5.7%. There were statistically significant differences in the rate of postoperative pulmonary complications (PPCs [57.7% vs. 35.8%; P < 0.001]), ventilator dependence (VD [63.2% vs. 46.3%; P < 0.001]), thromboembolic events (TEEs [22.9% vs. 12.9%; P = 0.009]), and in-hospital mortality (41.3% vs. 30.8%; P = 029) for patients with and without COPD. Independent of other covariates, the presence of COPD was not associated with a significantly increased risk of in-hospital mortality (OR, 1.16; 95% CI 0.70-1.97; P = 0.591) but was associated with an increased risk of PPCs (OR, 2.49; 95% CI 1.41-4.14; P = 0.002) and VD (OR, 2.26; 95% CI 1.22-4.17; P = 0.009). CONCLUSIONS Preexisting COPD may alter a patient's risk of PPCs and VD. However, it was not associated with an increased risk of in-hospital mortality.
Collapse
Affiliation(s)
- Woubet Tefera Kassahun
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, Faculty of Medicine, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Jonas Babel
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, Faculty of Medicine, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, Faculty of Medicine, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| |
Collapse
|
4
|
Heil TC, van Oostrum M, Holwerda E, Stegmann ME, van Munster BC, Brandenbarg D. Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation. J Am Med Dir Assoc 2024; 25:104887. [PMID: 38103569 DOI: 10.1016/j.jamda.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES Guidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation. DESIGN Historical prospective study. SETTING AND PARTICIPANTS Patients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database. METHODS Based on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice. RESULTS Compared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02). CONCLUSIONS AND IMPLICATIONS Although mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non-guideline adherence and a wait-and-see approach could be discussed in a shared-decision-making consultation.
Collapse
Affiliation(s)
- Thea C Heil
- Department of Geriatric Medicine, Radboud University Medical Center, University of Nijmegen, Nijmegen, the Netherlands
| | - Maartje van Oostrum
- Department of Primary and Long-Term Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Elodie Holwerda
- Department of Primary and Long-Term Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mariken E Stegmann
- Department of Primary and Long-Term Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Barbara C van Munster
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Daan Brandenbarg
- Department of Primary and Long-Term Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| |
Collapse
|
5
|
Pollack LR, Downey L, Nomitch JT, Lee RY, Engelberg RA, Weiss NS, Kross EK, Khandelwal N. Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure. Ann Am Thorac Soc 2024; 21:907-915. [PMID: 38323911 PMCID: PMC11160134 DOI: 10.1513/annalsats.202308-694oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024] Open
Abstract
Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.
Collapse
Affiliation(s)
- Lauren R. Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Jamie T. Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Robert Y. Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | | | - Erin K. Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| |
Collapse
|
6
|
Elzeneini M, Nassereddin AT, Li Y, Shah SK, Winchester D, Li A, Guo Y, Shah KB. Dementia is associated with worse procedural outcomes after mitral valve transcatheter edge-to-edge repair. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00119-2. [PMID: 38604834 DOI: 10.1016/j.carrev.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Patients with dementia are at increased risk for adverse events following valvular surgery. Outcomes after mitral transcatheter edge-to-edge repair (TEER) for mitral regurgitation in this vulnerable population are not well understood. METHODS We queried the National Inpatient Sample database for all hospitalizations for mitral TEER between 2016 and 2019. Patients with a validated diagnosis code for dementia were identified by ICD-10 codes and compared to a matched cohort of non-dementia patients using multivariable regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes were hospital length of stay, discharge to nursing facility, total hospital charges, and in-hospital adverse events. RESULTS 24,550 hospitalizations for mitral TEER were identified, including 880 patients (3.6 %) with dementia. Dementia was associated with higher in-hospital mortality (OR 4.31, 95 % CI 2.65 to 6.99, p < 0.001), prolonged length of hospital stay (OR 1.33, 95 % CI 1.12 to 1.57, p 0.001), higher discharge rate to nursing facility (OR 2.71, 95 % CI 2.13-3.44, p < 0.001), and higher rate of in-hospital adverse events including delirium (OR 5.88, 95 % CI 4.06 to 8.52, p < 0.001) and acute stroke (OR 8.87, 95 % CI 5.01 to 15.70, p < 0.001). CONCLUSIONS Dementia is associated with worse post-procedural outcomes after mitral TEER. Further investigation is needed to elucidate mechanisms of poor clinical outcomes and guide shared decision-making in this vulnerable population.
Collapse
Affiliation(s)
- Mohammed Elzeneini
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ali T Nassereddin
- Department of Internal Medicine, University of Florida, Gainesville, FL, United States of America
| | - Yujia Li
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States of America
| | - Samir K Shah
- Division of Vascular Surgery, University of Florida, Gainesville, FL, United States of America
| | - David Winchester
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ang Li
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States of America
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States of America
| | - Khanjan B Shah
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America.
| |
Collapse
|
7
|
Mueller KB, Hou Y, Beach K, Griffin LP. Development and validation of a point-of-care clinical risk score to predict surgical site complication-associated readmissions following open spine surgery. JOURNAL OF SPINE SURGERY (HONG KONG) 2024; 10:40-54. [PMID: 38567014 PMCID: PMC10982919 DOI: 10.21037/jss-23-89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/21/2023] [Indexed: 04/04/2024]
Abstract
Background Surgical site complications (SSCs) contribute to increased healthcare costs. Predictive analytics can aid in identifying high-risk patients and implementing optimization strategies. This study aimed to develop and validate a risk-assessment score for SSC-associated readmissions (SSC-ARs) in patients undergoing open spine surgery. Methods The Premier Healthcare Database (PHD) of adult patients (n=157,664; 3,182 SSC-ARs) between January 2019 and September 2020 was used for retrospective data analysis to create an SSC risk score using mixed effects logistic regression modeling. Full and reduced models were developed using patient-, facility-, or procedure-related predictors. The full model used 37 predictors and the reduced used 19. Results The reduced model exhibited fair discriminatory capability (C-statistic =74.12%) and demonstrated better model fit [Pearson chi-square/degrees of freedom (DF) =0.93] compared to the full model (C-statistic =74.56%; Pearson chi-square/DF =0.92). The risk scoring system, based on the reduced model, comprised the following factors: female (1 point), blood disorder [2], congestive heart failure [2], dementia [3], chronic pulmonary disease [2], rheumatic disease [3], hypertension [2], obesity [2], severe comorbidity [2], nicotine dependence [1], liver disease [2], paraplegia and hemiplegia [3], peripheral vascular disease [2], renal disease [2], cancer [1], diabetes [2], revision surgery [2], operative hours ≥5 [4], emergency/urgent surgery [2]. A final risk score (sum of the points for each surgery; range, 0-40) was validated using a 1,000-surgery random hold-out sample (C-statistic =85.16%). Conclusions The resulting SSC-AR risk score, composed of readily obtainable clinical information, could serve as a robust predictive tool for unplanned readmissions related to wound complications in the preoperative setting of open spine surgery.
Collapse
Affiliation(s)
- Kyle B. Mueller
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | |
Collapse
|
8
|
Ali K, Sakowitz S, Chervu NL, Verma A, Bakhtiyar SS, Curry J, Cho NY, Benharash P. Association of dementia with clinical and financial outcomes following lobectomy for lung cancer. JTCVS OPEN 2023; 16:965-975. [PMID: 38204693 PMCID: PMC10775042 DOI: 10.1016/j.xjon.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 01/12/2024]
Abstract
Objective The number of adults with dementia is rising worldwide. Although dementia has been linked with inferior outcomes following various operations, this phenomenon has not been fully elucidated among patients undergoing elective lung resection. Using a national cohort, we evaluated the association of dementia with clinical and financial outcomes following lobectomy for cancer. Methods Adults undergoing lobectomy for lung cancer were identified within the 2010-2020 Nationwide Readmissions Database. Patients with a comorbid diagnosis of dementia were considered the Dementia cohort (others: Non-Dementia). Multivariable regressions were developed to evaluate the association between dementia and key outcomes. Results Of ∼314,436 patients, 2863 (0.9%) comprised the Dementia cohort. Compared with Non-Dementia, the Dementia cohort was older (75 vs 68 years, P < .001), less commonly female (49.4 vs 53.9%, P = .01), and had a greater burden of comorbid conditions. After adjustment, dementia remained associated with similar odds of in-hospital mortality (adjusted odds ratio [aOR], 0.86; 95% confidence interval [CI], 0.54-1.38) but greater likelihood of pneumonia (aOR, 1.31; CI, 1.04-1.65) and infectious complications (aOR, 1.37; CI, 1.01-1.87). Further, dementia was associated with longer length of stay (β +0.96 days; CI, 0.51-1.41), but no difference in hospitalization cost (β $1528; CI, -92 to 3148). Conclusions Patients with dementia faced similar odds of mortality, but greater complications and resource use following lobectomy for lung cancer. Novel interventions are needed to improve care coordination and develop standardized recovery pathways for this growing cohort.
Collapse
Affiliation(s)
- Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Nikhil L. Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
- Department of Surgery, University of California, Los Angeles, Calif
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
- Department of Surgery, University of Colorado, Aurora, Colo
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Calif
- Department of Surgery, University of California, Los Angeles, Calif
| |
Collapse
|
9
|
Chen H, Devine M, Khan W, Khan IZ, Waldron R, Barry MK. The impact of psychiatric comorbidities on emergency general surgical patients' outcomes. Surgeon 2023; 21:289-294. [PMID: 36610867 DOI: 10.1016/j.surge.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Psychiatric disorders are increasingly prevalent. Studies have demonstrated that the presence of comorbid psychiatric conditions (CPC) is associated with a number of worsening outcomes in hospitalised patients in general. The relationship between a wide range of psychiatric comorbidities and acute surgical presentations has not been studied to date. STUDY DESIGN The Hospital In-Patient Enquiry (HIPE) system and prospectively maintained eHandover were used to identify all surgical emergency admissions to Mayo University Hospital, Ireland. Patient demographics, comorbidities, primary diagnoses, length of stay (LoS), and procedures undergone were recorded over a 12-months period. Subgroup analyses examining LoS variation in surgical presentation types were performed. RESULTS 1028 admissions occurred over this one year period, amongst 995 patients, the presence of psychiatric comorbidities increased the mean LoS by 1.9 days (p = 0.002). Comorbid depression, dementia, and intellectual disability conferred a significant increase in LoS by 2.4 days, 2.8 days and 6.7 days respectively. Subgroup analysis revealed greater LoS in patients with CPC diagnosed with non-specific abdominal pain (1.4 days, p = 0.019), skin and soft tissue infections (2.5 days, p = 0.040), bowel obstruction (4.3 days, p = 0.047), and medical disorders (18.6 days, p = 0.010). No significant difference was observed in mortality and readmission rates. CONCLUSION Psychiatric comorbidities significantly impact length of hospital stay and discharge planning in surgical inpatients. Greater awareness of this can facilitate better care delivery for this population to reduce the LoS and subsequent economic burden on the healthcare system.
Collapse
Affiliation(s)
- Hongying Chen
- Department of General Surgery, Mayo University Hospital, Castlebar, Co. Mayo, Ireland.
| | - Michael Devine
- Department of General Surgery, Mayo University Hospital, Castlebar, Co. Mayo, Ireland
| | - Waqar Khan
- Department of General Surgery, Mayo University Hospital, Castlebar, Co. Mayo, Ireland
| | - Iqbal Z Khan
- Department of General Surgery, Mayo University Hospital, Castlebar, Co. Mayo, Ireland
| | - Ronan Waldron
- Department of General Surgery, Mayo University Hospital, Castlebar, Co. Mayo, Ireland
| | - Michael K Barry
- Department of General Surgery, Mayo University Hospital, Castlebar, Co. Mayo, Ireland; Department of Breast Surgery, National University of Ireland Galway, Galway, Co. Galway, Ireland
| |
Collapse
|
10
|
Verma A, Branche C, Chervu NL, Sakowitz S, Bakhtiyar SS, Hadaya J, Benharash P. Dementia is Associated With Inferior Outcomes Following Emergency General Surgery. Am Surg 2023; 89:3994-3999. [PMID: 37132661 DOI: 10.1177/00031348231175447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Given the steadily aging United States population, we used a national database to examine the association of dementia with clinical and financial outcomes following emergency general surgery. METHODS All adults undergoing non-elective appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or lysis of adhesions were identified within the 2016-2019 Nationwide Readmissions Database. Entropy balancing and multivariable regressions were used to assess the risk-adjusted association between dementia and in-hospital mortality, complications, length of stay, costs, non-home discharge, and 30-day unplanned readmissions. RESULTS Of an estimated 1,332,922 patients, 2.7% had dementia. Compared to those without, patients with dementia were older, more commonly male, and had a greater burden of chronic conditions. Following entropy balancing and multivariable risk-adjustment, dementia was associated with increased odds of mortality and sepsis across all operations except perforated ulcer repair. Dementia was also linked to greater likelihood of pneumonia across all operative categories. Moreover, dementia was associated with increased length of stay for patients in all operative categories except perforated ulcer repair, while costs were only increased for those undergoing appendectomy, cholecystectomy, and lysis of adhesions. Dementia was also linked to higher odds of non-home discharge following all operations, while non-elective readmissions were only increased for patients undergoing cholecystectomy. CONCLUSIONS The present study found dementia to be associated with a significant clinical and financial burden. Our findings may help inform shared decision making with patients and their families.
Collapse
Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| |
Collapse
|
11
|
Clark CJ, Adler R, Xiang L, Shah SK, Cooper Z, Kim DH, Lin KJ, Hsu J, Lipsitz S, Weissman JS. Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study. Am J Surg 2023; 226:108-114. [PMID: 37031040 PMCID: PMC10330079 DOI: 10.1016/j.amjsurg.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery. METHODS Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes. RESULTS 5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001). CONCLUSIONS The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.
Collapse
Affiliation(s)
- Clancy J Clark
- Division of Surgical Oncology, Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
| | - Rachel Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Samir K Shah
- Division of Vascular Surgery, Department of General Surgery, University of Florida, Gainesville, FL, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John Hsu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
12
|
Maganty A, Dunn RL, Bynum JPW, Hollenbeck BK. Accountable care organizations and use of surgery among patients with Alzheimer disease and related dementias. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:349-355. [PMID: 37523752 PMCID: PMC10403270 DOI: 10.37765/ajmc.2023.89395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To understand the effects of accountable care organizations (ACOs) on use of surgery in patients with Alzheimer disease and related dementias (ADRD). STUDY DESIGN Retrospective national cohort study of all Medicare beneficiaries identified in a 20% sample between 2010 and 2017. The primary exposure was participation in ACOs. The primary outcome was use of 1 of 6 common surgical procedures (aortic valve replacement [AVR], abdominal aortic aneurysm [AAA] repair, colectomy, carotid artery repair, major joint repair, and prostatectomy). METHODS Multivariable logistic regression models were fit using beneficiary-year as the unit of analysis to estimate the likelihood of undergoing each procedure among patients with ADRD and without ADRD, stratified by ACO participation. Additional models were fit to determine how the relationship between ACO participation and surgery was altered based on procedure urgency and the availability of minimally invasive technology. RESULTS Adjusted odds for use of surgery were lower among patients with ADRD compared with patients without ADRD for all procedures. ACO participation had varying impact on patients with ADRD, with higher odds of AVR and major joint surgery and lower odds of carotid artery repair. Availability of minimally invasive technology increased the likelihood of AVR and AAA repair among patients with ADRD; however, ACO participation reduced these effects. The effect of ACO participation on the likelihood of undergoing surgery did not vary by urgency of the procedure. CONCLUSIONS The likelihood of undergoing surgery is overall lower among patients with ADRD and may vary by ACO participation for specific procedures.
Collapse
Affiliation(s)
- Avinash Maganty
- Division of Health Services Research, Department of Urology, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ann Arbor, MI 48109-2800.
| | | | | | | |
Collapse
|
13
|
Kovaleva MA, Kleinpell R, Dietrich MS, Jones AC, Boon JT, Duggan MC, Dennis BM, Lauderdale J, Maxwell CA. Caregivers’ experience with Tele-Savvy Caregiver Program post-hospitalization. Geriatr Nurs 2023; 51:156-166. [PMID: 36990041 DOI: 10.1016/j.gerinurse.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/30/2023]
Abstract
Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.
Collapse
Affiliation(s)
- Mariya A Kovaleva
- College of Nursing - Omaha Division, University of Nebraska Medical Center, 985330 Nebraska Medical Center, Omaha, NE 68198-5330, USA.
| | - Ruth Kleinpell
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| | - Mary S Dietrich
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Department of Biostatistics, Vanderbilt University School of Medicine, 1161 21st Ave S, #D3300, Nashville, TN 37232, USA
| | - Abigail C Jones
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Yale University School of Nursing, 400 West Campus Drive, Orange, CT 06477, USA
| | - Jeffrey T Boon
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA; Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Maria C Duggan
- Division of Geriatric Medicine, Vanderbilt University School of Medicine, 1161 21st Ave S, #D3300, Nashville, TN 37232, USA; Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, 1310 24th Ave South, Nashville, TN 37212-2637, USA
| | - Bradley M Dennis
- Division of Acute Care Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Jana Lauderdale
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| | - Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Ave S, Nashville, TN 37240, USA
| |
Collapse
|
14
|
Kent I, Ghuman A, Sadran L, Rov A, Lifschitz G, Rudnicki Y, White I, Goldberg N, Avital S. Emergency Colectomies in the Elderly Population—Perioperative Mortality Risk-Factors and Long-Term Outcomes. J Clin Med 2023; 12:jcm12072465. [PMID: 37048549 PMCID: PMC10095288 DOI: 10.3390/jcm12072465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023] Open
Abstract
Background: As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is scarce. Methods: A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded. Results: Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18–59, 60–69, 70–79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60–69, 70–79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups. Conclusion: Perioperative mortality with emergency colectomy increases with patients’ age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.
Collapse
|
15
|
Daniels SL, Morgan J, Lee MJ, Wickramasekera N, Moug S, Wilson TR, Brown SR, Wyld L. Surgeon preference for treatment allocation in older people facing major gastrointestinal surgery: an application of the discrete choice experiment methodology. Colorectal Dis 2023; 25:102-110. [PMID: 36161457 PMCID: PMC10087205 DOI: 10.1111/codi.16296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/30/2022] [Accepted: 07/31/2022] [Indexed: 02/02/2023]
Abstract
AIM Variation in major gastrointestinal surgery rates in the older population suggests heterogeneity in surgical management. A higher prevalence of comorbidities, frailty and cognitive impairments in the older population may account for some variation. The aim of this study was to determine surgeon preference for major surgery versus conservative management in hypothetical patient scenarios based on key attributes. METHOD A survey was designed according to the discrete choice methodology guided by a separate qualitative study. Questions were designed to test for associations between key attributes (age, comorbidity, urgency of presentation, pathology, functional and cognitive status) and treatment preference for major gastrointestinal surgery versus conservative management. The survey consisting of 18 hypothetical scenarios was disseminated electronically to UK gastrointestinal surgeons. Binomial logistic regression was used to identify associations between the attributes and treatment preference. RESULTS In total, 103 responses were received after 256 visits to the questionnaire site (response rate 40.2%). Participants answered 1847 out of the 1854 scenarios (99.6%). There was a preference for major surgery in 1112/1847 (60.2%) of all scenarios. Severe comorbidities (OR 0.001, 95% CI 0.000-0.030; P = 0.000), severe cognitive impairment (OR 0.001, 95% CI 0.000-0.033; P = 0.000) and age 85 years and above (OR 0.028, 95% CI 0.005-0.168; P = 0.000) were all significant in the decision not to offer major gastrointestinal surgery. CONCLUSION This study has demonstrated variation in surgical treatment preference according to key attributes in hypothetical scenarios. The development of fitness-stratified guidelines may help to reduce variation in surgical practice in the older population.
Collapse
Affiliation(s)
- Sarah L Daniels
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jenna Morgan
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Susan Moug
- Royal Alexandra Hospital, Glasgow, UK.,University of Glasgow, Glasgow, UK
| | - Tim R Wilson
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | - Steven R Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| |
Collapse
|
16
|
Development and validation of a point-of-care clinical risk score to predict surgical site infection following open spinal fusion. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 13:100196. [PMID: 36691580 PMCID: PMC9860512 DOI: 10.1016/j.xnsj.2022.100196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/25/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
Background Surgical site infection (SSI) after open spine surgery increases healthcare costs and patient morbidity. Predictive analytics using large databases can be used to develop prediction tools to aid surgeons in identifying high-risk patients and strategies for optimization. The purpose of this study was to develop and validate an SSI risk-assessment score for patients undergoing open spine surgery. Methods The Premier Healthcare Database of adult open spine surgery patients (n = 157,664; 2,650 SSIs) was used to create an SSI risk scoring system using mixed effects logistic regression modeling. Full and reduced multilevel logistic regression models were developed using patient, surgery or facility predictors. The full model used 38 predictors and the reduced used 16 predictors. The resulting risk score was the sum of points assigned to 16 predictors. Results The reduced model showed good discriminatory capability (C-statistic = 0.75) and good fit of the model ([Pearson Chi-square/DF] = 0.90, CAIC=25,517) compared to the full model (C-statistic = 0.75, [Pearson Chi-square/DF] =0.90, CAIC=25,578). The risk scoring system, based on the reduced model, included the following: female (5 points), hypertension (4), blood disorder (8), peripheral vascular disease (9), chronic pulmonary disease (6), rheumatic disease (16), obesity (12), nicotine dependence (5), Charlson Comorbidity Index (2 per point), revision surgery (14), number of ICD-10 procedures (1 per procedure), operative time (1 per hour), and emergency/urgent surgery (12). A final risk score as the sum of the points for each surgery was validated using a 1,000-surgery random hold-out (independent from the study cohort) sample (C-statistic = 0.77). Conclusions The resulting SSI risk score composed of readily obtainable clinical information could serve as a strong prediction tool for SSI in preoperative settings when open spine surgery is considered.
Collapse
|
17
|
Koto T, Kurihara Y, Shoji M, Meguro K. Avoiding surgery in patients with dementia: is it the correct management? Dement Neuropsychol 2022. [DOI: 10.1590/1980-5764-dn-2021-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT. Although hospitalization for dementia is increasing, Japanese doctors often refrain from surgeries considering dementia. A woman in her 80s diagnosed with Alzheimer’s disease was admitted to hospital for cholelithiasis. Due to the avoidance of surgery, the inflammation was prolonged and therefore she was unable to eat. Later, she was discharged with central venous nutrition. The care burden on family resulted in her readmission to another hospital. Eventually, the inflammation was alleviated, and she was able to eat. However, it took a long time. In this study, we not only emphasize the risks but also focus on the benefits to postoperative rehabilitation. We also discuss about the benefits of invasive procedures in patients with dementia.
Collapse
Affiliation(s)
| | | | | | - Kenichi Meguro
- Tohoku University, Japan; Tohoku University, Japan; Tohoku University, Japan
| |
Collapse
|
18
|
The Collective Influence of Social Determinants of Health on Individuals Who Underwent Lumbar Spine Revision Surgeries: A Retrospective Cohort Study. World Neurosurg 2022; 165:e619-e627. [PMID: 35772707 DOI: 10.1016/j.wneu.2022.06.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To analyze the collective effect of social determinants of health (SDH) on lumbar spine revision surgery outcomes using a retrospective cohort study design. METHODS Data from the Quality Outcomes Database were used, including 7889 adults who received lumbar spine revision surgery and completed 3 and 12 months' follow-up. The SDH of interest included race/ethnicity, educational attainment, employment status, insurance payer, and sex. A stepwise regression model using each number of SDH conditions present (0 of 5, 1 of 5, 2 of 5, ≥3 of 5) was used to assess the collective influence of SDH. The odds of demonstrating a minimum clinically important difference was evaluated in back and leg, disability, quality of life, and patient satisfaction at 3-months and 12-months follow-up. RESULTS An additive effect for SDH was found across all outcome variables at 3 and 12 months. Individuals with ≥3 SDH were at the lowest odds of meeting the minimum clinically important difference of each outcome. At 12 months, individuals with ≥3 SDH had a 67%, 65%, 71%, 65%, and 46% decrease in the odds of a clinically meaningful outcome in back and leg pain, disability, quality of life, and patient satisfaction. CONCLUSIONS Health care teams should evaluate SDH in individuals who may be considered for lumbar spine revision surgery. Viewing social factors in aggregate may be useful as a screening tool for lumbar spine revision surgeries to identify at risk patients who may require pre-emptive care strategies and postoperative resources to mitigate these risks.
Collapse
|
19
|
Kim H, Juarez CA, Meath THA, Quiñones AR, Teno JM. Association of Medicare bundled payment model with joint replacement care for people with dementia. J Am Geriatr Soc 2022; 70:2571-2581. [PMID: 35635471 PMCID: PMC9489623 DOI: 10.1111/jgs.17836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 04/17/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND We examined whether the Comprehensive Care for Joint Replacement (CJR) model was associated with changes in the receipt of joint replacement among people with Alzheimer's disease and related dementias (ADRD) as well as spending, health service use, and postsurgical outcomes among people with ADRD who underwent a joint replacement surgery. METHODS Retrospective cohort study using 2013-2017 Medicare claims and Minimum Data Set. We used a difference-in-differences analysis to compare people with ADRD residing in CJR-participating treatment areas versus nonparticipating control areas on the receipt of joint replacement, episode spending during the index hospitalization and subsequent 90-day post-discharge period, discharges to an institutional post-acute care setting, and readmissions within 90 days of hospital discharge. RESULTS Our sample included 3,361,950 Medicare enrollees with ADRD (2,156,995 women [64%]; mean [SD] age, 83 [8.0] years; 2,646,405 white [78%], 344,478 black [10%], 224,010 Hispanic [7%]). The receipt of replacement among people with ADRD changed similarly between CJR-participating treatment and control areas after CJR model was implemented, suggesting no association of CJR model with the receipt of replacement. Among people with ADRD who received joint replacement, the CJR model was associated with a $1029 decrease in spending per episode (95% confidence interval [CI] -$1577, -$481, p < 0.001), a 1.62 percentage point decrease in discharges to an institutional post-acute care setting (95% CI -3.17, -0.07, p = 0.04), but no changes in 90-day readmission (95% CI -2.68, 0.00, p = 0.051). CONCLUSIONS Despite concerns that the CJR model could hinder people with ADRD from receiving joint replacement, the receipt of joint replacement did not change among people with ADRD under CJR. The CJR model was associated with decreased spending for people with ADRD who received joint replacements, driven by reduced discharges to an institutional post-acute care setting, without any changes in 90-day readmission.
Collapse
Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Cesar A Juarez
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas H A Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joan M Teno
- Department of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
20
|
Lester PE, Ripley D, Grandelli R, Drew LA, Keegan M, Islam S. Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation. J Am Med Dir Assoc 2022; 23:555-562. [PMID: 35227669 DOI: 10.1016/j.jamda.2022.01.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75 years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee. Our intervention group was compared to surgical patients during the same time period 1 year prior to the intervention, and the groups were well matched in demographics and comorbidities. The intervention group had significantly higher rates of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P = .006). The preintervention group had less postoperative delirium compared to the postintervention group but it was not significant and there was no difference in length of stay between groups. Various explanations for the minimal impact of the protocol exist: small sample size, presence of other hospital initiatives to reduce pressure ulcer and delirium, and clinician's awareness of project planning that led to incorporating ideas prior to official implementation. Future research implementing this protocol in naïve and/or underperforming institutions may demonstrate a greater effect. Larger sample size as well as implementation in other surgical fields may reveal a significant impact. However, if additional study does not reveal a meaningful impact of a comprehensive geriatric assessment for surgical patients, then consideration must be made regarding unrecognized factors in surgical care for older adults or perhaps that factors cannot be mitigated in older adults because they are intrinsically a higher surgical risk.
Collapse
|
21
|
Anterior Cervical Discectomy and Fusion in patients with Preexisting Dementia: Increased Medical Complications, Costs, and 90-Day Readmissions. Clin Neurol Neurosurg 2022; 215:107182. [DOI: 10.1016/j.clineuro.2022.107182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/03/2022]
|
22
|
Yokoyama K, Ukai T, Watanabe M. Effect of nutritional status before femoral neck fracture surgery on postoperative outcomes: a retrospective study. BMC Musculoskelet Disord 2021; 22:1027. [PMID: 34879851 PMCID: PMC8656010 DOI: 10.1186/s12891-021-04913-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022] Open
Abstract
Background Although nutritional status is crucial in gait recovery after femoral neck fracture surgery, the relationship between preoperative nutritional status and postoperative outcomes remains unknown. This study examined the effects of preoperative nutritional status on postoperative outcomes in patients undergoing femoral neck fracture surgery. Methods Data regarding the joints of 137 patients (29 men, 108 women) who underwent bipolar hemiarthroplasty for femoral neck fractures at our hospital from January 2015 to December 2019 were retrospectively examined. The Geriatric Nutritional Risk Index (GNRI), an index of nutritional status, was used to classify patients into two groups: a normal group (GNRI ≥92; n = 62) and an undernourished group (GNRI < 92; n = 75). The study endpoints included age at surgery, sex, Mini Mental State Examination (MMSE), American Society of Anesthesiologists Physical Status (ASA) classification, preoperative waiting period, intraoperative blood loss, surgery time, perioperative hemoglobin levels, blood transfusion rate, complication rate, 6-month mortality rate, transfer rate, percentage of patients unable to walk at discharge or transfer, and inability to walk 6 months postoperatively. Results The patients in the undernourished group was significantly older at surgery (p < 0.01) and had a lower perioperative hemoglobin levels (p < 0.01), a higher blood transfusion rate (p < 0.01), a lower MMSE (p < 0.01), a longer preoperative waiting period (p < 0.05), a higher transfer rate (p < 0.05), were more likely to be unable to walk 6 months postoperatively (p < 0.01), a higher complication rate (p < 0.05), and a higher 6-month mortality rate (p < 0.01) than the normal group. Patients in the undernourished group had worse rates of postoperative complications, transfer, mortality, and inability to walk 6-month after surgery than those in the normal group. Conclusions A poor nutritional status affects the gait function and systemic condition of patients undergoing femoral neck fracture surgery; therefore, early nutritional interventions may reduce mortality rates and shorten rehabilitation. These results suggest that the GNRI effectively predicts postoperative complications, mortality, and gait function.
Collapse
Affiliation(s)
- Katsuya Yokoyama
- Department of Orthopedic Surgery, Tokai University School of Medicine Oiso Hospital, 21-1 Gekkyo, Oiso, Kanagawa, 259-0198, Japan
| | - Taku Ukai
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Masahiko Watanabe
- Department of Orthopedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| |
Collapse
|
23
|
Skorus U, Rapacz K, Kenig J. The significance of comorbidity burden among older patients undergoing abdominal emergency or elective surgery. Acta Chir Belg 2021; 121:405-412. [PMID: 32873179 DOI: 10.1080/00015458.2020.1816671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Comorbidities may cause complications in perioperative care and affect treatment outcomes of older patients. The study aim was to analyse comorbidity burdens with respect to their predictive power in outcome prediction in elderly qualified for abdominal elective or emergency surgery. METHODS Consecutive patients undergoing major abdominal surgery between 2010 and 2017 at a secondary referral hospital were included in the retrospective study, for a total of 1586 patients. To explain the relationship between the comorbidity types and 30-day mortality and morbidity logistic regression analysis was performed. Morbidity was assessed using the Clavien-Dindo Score. Major complications were defined as a C-D score ≥ 3. We also presented the data concerning need for reoperation and ICU admission. RESULTS 85.9% of patients had at least one comorbidity. In the group of emergency patients age and number of comorbidities were independent risk factors of 30-day mortality and major morbidity. In elective patients age, dementia (OR:3.52; 95%CI:1.35-9.20) and kidney disease (OR:1.64; 95%CI:1.04-2.57) were found to be independent risk factors of 30-day postoperative mortality. Age (1.04; 95%CI:1.00-1.08) and heart disease (OR:1.30, 95%CI:1.04-1.63) were found to be independent risk factors of 30-day major morbidity. CONCLUSIONS In patients undergoing elective surgery 30-day mortality and morbidity was associated with age. 30-day mortality, but not morbidity was associated with kidney disease and dementia. 30-day morbidity, but not mortality, was associated with heart disease.
Collapse
Affiliation(s)
- Urszula Skorus
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Kamil Rapacz
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Kenig
- Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
24
|
Mcswain JR, Sirianni JM, Wilson SH. Perioperative Considerations for Patients with a Known Diagnosis of Dementia. Adv Anesth 2021; 39:113-132. [PMID: 34715970 DOI: 10.1016/j.aan.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Julie R Mcswain
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Drive, Suite 4200 MSC 240, Charleston, SC 29425, USA.
| | - Joel M Sirianni
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301 MSC 912, Charleston, SC, USA
| | - Sylvia H Wilson
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301 MSC 912, Charleston, SC, USA
| |
Collapse
|
25
|
Sura-Amonrattana U, Tharmviboonsri T, Unnanuntana A, Tantigate D, Srinonprasert V. Evaluation of the implementation of multidisciplinary fast-track program for acute geriatric hip fractures at a University Hospital in resource-limited settings. BMC Geriatr 2021; 21:548. [PMID: 34641804 PMCID: PMC8513216 DOI: 10.1186/s12877-021-02509-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022] Open
Abstract
Background Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes. Methods A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital before and after implementation of the Fast-track program for Acute Geriatric Hip Fractures. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation. Results Three hundred two patients were enrolled from the Siriraj hospital’s database from October 2016 to October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p < 0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-h (80.3% VS 44.7%, p < 0.001) and the length of stay was significantly shorter (11 days (8–17) VS 13 days (9–18), p = 0.017). There was no significant difference in medical complications. Stratified analysis by dementia status showed a trend in delirium reduction in both patients with dementia and without dementia groups, and a pressure injury reduction among patients with dementia after the program was implemented but without statistical significance. There was no significant difference in mortality. Conclusions The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited setting. In the Fast-track program, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines.
Collapse
Affiliation(s)
- Unchana Sura-Amonrattana
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Theerawoot Tharmviboonsri
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Aasis Unnanuntana
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Direk Tantigate
- Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Department of Medicine, Division of Geriatric Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
26
|
Au Yong PSA, Sim EYL, Ho CYX, He Y, Kwa CXW, Teo LM, Abdullah HR. Association of Multimorbidity With Frailty in Older Adults for Elective Non-Cardiac Surgery. Cureus 2021; 13:e15033. [PMID: 34150384 PMCID: PMC8200322 DOI: 10.7759/cureus.15033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Frailty is associated with adverse surgical outcomes. While existing studies describe the prevalence of multimorbidity and frailty in the community, the surgical population may have more severe disease and significant surgical stress. This study aims to describe the distribution of frailty and multimorbidity in the older surgical population and examine if specific comorbidities are more strongly associated with frailty. Methods This is a single-centre retrospective cohort study using an electronic database in the preoperative evaluation clinic, conducted in Singapore General Hospital, Singapore. All patients above 70 years old going for elective non-cardiac surgery were included. Demographics and comorbidities were analysed for their association with frailty according to the Edmonton Frail Scale. Results A total of 1396 out of 1398 patients were analyzed. The overall incidence of frailty was 27.8% and multimorbidity was 63.4%. Factors independently associated with frailty were age (adjusted Odds Ratio [aOR] = 1.07), female gender (aOR = 1.67), type 2 diabetes mellitus (aOR = 1.69), chronic kidney disease (aOR = 1.47), end-stage renal failure (aOR = 3.58), history of cerebrovascular accident or transient ischemic attack (aOR = 1.87), moderate anaemia (aOR = 2.11), dementia (aOR = 6.38), depression (aOR = 3.82), and peptic ulcer disease (aOR = 1.98). The presence of multi-morbidity was significantly associated with frailty, with overall increasing strength of association. Conclusion As the number of comorbidities increases, the odds of frailty increase. Only a small proportion of those with multimorbidity accumulate enough biological deficits to develop frailty, putting them at higher risk than with solely multimorbidity or frailty. Dementia and depression are comorbidities with strong associations that have yet to see coordinated interventional efforts in the preoperative setting.
Collapse
Affiliation(s)
- Phui Sze Angie Au Yong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| | - Eileen Yi Lin Sim
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| | - Collin Yih Xian Ho
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| | - Yingke He
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| | - Charlene Xian Wen Kwa
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| | - Li Ming Teo
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| | - Hairil Rizal Abdullah
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, SGP
| |
Collapse
|
27
|
Changes in Health-Related Quality of Life for Older Persons With Cognitive Impairment After Hip Fracture Surgery: A Systematic Review. J Nurs Res 2021; 28:e97. [PMID: 31985559 DOI: 10.1097/jnr.0000000000000371] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hip fractures in persons with cognitive impairments represent a major public health issue in older populations that often results in poor health-related quality of life (HRQoL). PURPOSE The aim of this systemic review was to examine the changes in HRQoL in older, cognitively impaired patients with hip fracture who had received surgical treatment. METHODS A literature search of PubMed, Scopus, MEDLINE, PsycINFO, and CINAHL (EBSCO) databases was conducted for studies published up to July 2018 that addressed the issue of HRQoL in cognitively impaired patients with hip fracture after surgery. Studies that met the following criteria were included: Patients with hip fracture were over 60 years old and had cognitive impairment or dementia, patients had undergone hip fracture repair surgery, HRQoL was determined using standardized questionnaires, a descriptive or interventional methodology was used, and the full-text article was available in English. RESULTS A primary search of databases yielded 1,528 studies, 621 duplicates were removed, and the remaining 907 abstracts were screened. Thirty-four full-text articles were deemed relevant for full review; of these, 10 articles met the criteria for inclusion in the review. Cognitive impairment was found to impact negatively on the patients' HRQoL after hip fracture surgery (n = 809). Severity of cognitive impairment was correlated with deterioration in HRQoL after hospital discharge. When compared with prefracture measures of HRQoL, the greatest deterioration in HRQoL postsurgery occurred during the first 4 months after discharge. Impacts on HRQoL for patients with cognitive impairment at later time points differed depending on type of hip fracture and type of surgical treatment. However, for most of the patients, HRQoL remained relatively unchanged at 6, 12, and 24 months postdischarge. CONCLUSIONS We recommend nursing care interventions for older persons with cognitive impairment be initiated immediately after surgery for hip fracture to prevent a significant decline in HRQoL. Further examination of interventions that are effective in maintaining HRQoL for these patients such as interdisciplinary care is necessary. In addition, the influences of hip fracture type and surgical approach on changes in HRQoL suggest a need for further investigations to determine what contributed to the observed inconsistencies in the outcomes.
Collapse
|
28
|
Wu YM, Kuo HC, Li CC, Wu HL, Chen JT, Cherng YG, Chen TJ, Dai YX, Liu HY, Tai YH. Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228431. [PMID: 33202564 PMCID: PMC7696268 DOI: 10.3390/ijerph17228431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023]
Abstract
Patients with dementia are predisposed to multiple physiological abnormalities. It is uncertain if dementia associates with higher rates of perioperative mortality and morbidity. We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching analyses to evaluate the risk of mortality and major complications in patients with or without dementia undergoing major surgery between 2004 and 2013. We applied multivariable logistic regressions to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for the outcome of interest. After matching to demographic and clinical covariates, 7863 matched pairs were selected for analysis. Dementia was significantly associated with greater risks of 30-day in-hospital mortality (aOR: 1.71, 95% CI: 1.09–2.70), pneumonia (aOR: 1.48, 95% CI: 1.16–1.88), urinary tract infection (aOR: 1.59, 95% CI: 1.30–1.96), and sepsis (OR: 1.77, 95% CI: 1.34–2.34) compared to non-dementia controls. The mortality risk in dementia patients was attenuated but persisted over time, 180 days (aOR: 1.49, 95% CI: 1.23–1.81) and 365 days (aOR: 1.52, 95% CI: 1.30–1.78) after surgery. Additionally, patients with dementia were more likely to receive blood transfusion (aOR: 1.32, 95% CI: 1.11–1.58) and to need intensive care (aOR: 1.40, 95% CI: 1.12–1.76) compared to non-dementia controls. Senile dementia and Alzheimer’s disease were independently associated with higher rates of perioperative mortality and complications, but vascular dementia was not affected. We found that preexisting dementia was associated with mortality and morbidity after major surgery.
Collapse
Affiliation(s)
- Yu-Ming Wu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsien-Cheng Kuo
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chun-Cheng Li
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsiang-Ling Wu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan; (T.-J.C.); (Y.-X.D.)
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Tzeng-Ji Chen
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan; (T.-J.C.); (Y.-X.D.)
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Ying-Xiu Dai
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan; (T.-J.C.); (Y.-X.D.)
- Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Hsin-Yi Liu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (Y.-M.W.); (H.-C.K.); (C.-C.L.); (J.-T.C.); (Y.-G.C.); (H.-Y.L.)
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence:
| |
Collapse
|
29
|
Li X, Du W, Parkinson A, Glasgow N. Postoperative Delirium Following Joint Replacement in Patients With Dementia in New South Wales, Australia: A State-Wide Retrospective Cohort Study. Res Gerontol Nurs 2020; 13:243-253. [PMID: 32101321 DOI: 10.3928/19404921-20200214-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/16/2019] [Indexed: 11/20/2022]
Abstract
The objective of the current study was to investigate the variation in postoperative delirium in patients with dementia undergoing joint replacement in New South Wales (NSW) Australia public hospitals, identify factors related to its occurrence, and explore the volume-outcome relationship. The NSW Admitted Patient Data (July 2001 to June 2014) were used in this study and included patients with dementia undergoing joint replacement who were 65 or older with minor to severe comorbidities. Mixed-effect logistic models were applied to investigate hospital-level variation and factors associated with postoperative delirium. The between-hospital variability of postoperative delirium was 0.19% prior to 2008-2009 and 8.32% after 2008-2009. Hospital volume was not inversely associated with postoperative delirium rate. During 2001-2014, the incidence of postoperative delirium increased by 13% per annum (95% confidence interval [CI] 10% to 16%), while it increased by 15% per annum (95% CI 8% to 22%) after 2008-2009. An integrated approach addressing complex needs of patients with dementia may reduce the observed unwarranted variation and improve surgical outcomes. [Research in Gerontological Nursing, 13(5), 243-253.].
Collapse
|
30
|
Ninomiya S, Amano S, Ogawa T, Ueda Y, Shiraishi N, Inomata M, Shimoda K. The impact of dementia on surgical outcomes of laparoscopic cholecystectomy for symptomatic cholelithiasis and acute cholecystitis: A retrospective study. Asian J Endosc Surg 2020; 13:351-358. [PMID: 31389183 DOI: 10.1111/ases.12743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/03/2019] [Accepted: 07/17/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aim of this study was to clarify the impact of dementia on surgical outcomes of laparoscopic cholecystectomy for symptomatic cholelithiasis and acute cholecystitis. METHODS We reviewed medical data of 96 patients who underwent laparoscopic cholecystectomy for symptomatic cholecystitis and acute cholecystitis. The patients were divided into the dementia group (n = 18) and non-dementia group (n = 78). Clinical features of the patients and surgical outcomes were compared between the two groups. RESULTS Mean age and rates of The American Society of Anesthesiologists Physical Status classification score > 2 in the dementia group were significantly higher than those of the non-dementia group (P < .001, P = .008, respectively). Incidences of acute cholecystitis and the rate of percutaneous transhepatic gallbladder drainage in the dementia group were significantly higher than those of the non-dementia group (P = .009, P = .01, respectively). The rates of conversion to laparotomy and non-surgical complications in the dementia group were higher than those in the non-dementia group (P = .02, P = .03, respectively). Postoperative hospital stay in the dementia group was significantly longer than that in the non-dementia group (15.2 ± 9.3 vs 8.2 ± 3.2 days, P = .009). Subgroup analysis of patients with acute cholecystitis showed postoperative hospital stay in the dementia group to be significantly longer than that in the non-dementia group (18.7 ± 10.7 vs 10.3 ± 4.2 days, P = .03). CONCLUSION Patients with dementia who underwent laparoscopic cholecystectomy have a high incidence of acute cholecystitis and a high rate of percutaneous transhepatic gallbladder drainage, which may result in increased rates of conversion to laparotomy and prolong the postoperative hospital stay.
Collapse
Affiliation(s)
- Shigeo Ninomiya
- Department of Surgery, Cosmos Hospital, Usuki, Japan.,Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Japan
| | - Shota Amano
- Department of Surgery, Cosmos Hospital, Usuki, Japan
| | - Tadashi Ogawa
- Department of Surgery, Cosmos Hospital, Usuki, Japan
| | - Yoshitake Ueda
- Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Norio Shiraishi
- Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Japan
| | | |
Collapse
|
31
|
Masutani R, Pawar A, Lee H, Weissman JS, Kim DH. Outcomes of Common Major Surgical Procedures in Older Adults With and Without Dementia. JAMA Netw Open 2020; 3:e2010395. [PMID: 32662842 PMCID: PMC7361650 DOI: 10.1001/jamanetworkopen.2020.10395] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This cross-sectional study uses data from the Premier Healthcare Database to compare in-hospital mortality, home discharge, and hospital length of stay among older adults with and without dementia who have undergone major surgical procedures.
Collapse
Affiliation(s)
- Rebecca Masutani
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Hemin Lee
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
| |
Collapse
|
32
|
Safety of leadless pacemaker implantation in the very elderly. Heart Rhythm 2020; 17:2023-2028. [PMID: 32454218 DOI: 10.1016/j.hrthm.2020.05.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Micra leadless pacemaker (MLP) has proven to be an effective alternative to a traditional transvenous pacemaker (TVP). However, there has been concern about using the MLP in frail elderly patients because of the size of the implant sheath and perceived risk of perforation. OBJECTIVES The objectives of this study were to report the safety of the MLP and compare MPLs with TVPs in the very elderly. METHODS All patients 85 years and older who received an MLP or a single-chamber TVP across 6 hospitals in the Northwell Health system from December 2015 to November 2019 were included. Demographic characteristics, procedural details, and procedure-related complications were reviewed. RESULTS Over 4 years, 564 patients underwent MLP implantation. During this time, 183 MLPs and 119 TVPs were implanted in patients 85 years and older. The mean age was 89.7 ± 3.4 years, and 47.4% were men. MLP implantation was successful in all but 3 patients (98.4% success rate). There was no difference in procedure-related complications (3.3% vs 5.9%; P = .276). Complications included 5 (2.7%) access site hematomas in the MLP group, 3 (2.5%) in the TVP group, 1 (0.5 vs 0.8%) pericardial effusion in each group, and 3 (2.5%) acute lead dislodgments (<24 hours) in the TVP group. MLP implantation resulted in a significantly shorter mean procedure time (35.7 ± 23.0 minutes vs 62.3 ± 31.5 minutes, P < .001). CONCLUSION In a large multicenter study of patients 85 years and older, MLP implantation (1) was successful in 98.4% of patients, (2) was safe with no difference in procedure-related complications compared to the TVP group, and (3) resulted in significantly shorter procedure times.
Collapse
|
33
|
Henke P. Assessment for dementia in vascular surgical patients should be routine. J Vasc Surg 2020; 71:1691. [PMID: 32334730 DOI: 10.1016/j.jvs.2019.08.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/26/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Peter Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| |
Collapse
|
34
|
Kruthiventi SC, Laporta ML, Deljou A, Knopman DS, Petersen RC, Schroeder DR, Sprung J, Weingarten TN. Preoperative cognitive impairment associated with oversedation during recovery from anesthesia. J Anesth 2020; 34:390-396. [PMID: 32222908 DOI: 10.1007/s00540-020-02764-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/22/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Our objective was to examine the association between preoperative cognitive status and postoperative recovery from anesthesia. METHODS We included patients (70-91 years old) from the Mayo Clinic Study of Aging who received general anesthesia and were admitted to the postanesthesia care unit from January 1, 2010 through April 30, 2018. Procedures were categorized according to patient's preoperative cognitive status: cognitive impaired (CI) and cognitive unimpaired (CU). Perioperative records were reviewed and analyses were performed with generalized estimating equations. RESULTS A total of 896 procedures from 611 patients were included, with 203 (22.7%) procedures in the CI group. Compared to CU procedures, CI procedures had higher rates of moderate-deep sedation during anesthesia recovery (52 [25.6%] vs. 103 [14.9%]; odds ratio [OR], 1.91; 95% CI, 1.30-2.80; P < 0.01), postoperative pulmonary complications (22 [10.8%] vs. 34 [4.9%]; OR, 2.36[1.22-4.54]; P = 0.01), and postoperative delirium (32 [16.2%] vs. 24 [3.5%]; OR, 5.33 [2.88-9.86]; P < 0.01). When moderate-deep sedation during anesthesia recovery was a covariate, both CI (OR, 3.02[1.60-5.70]; P < 0.01) and moderate-deep sedation (OR, 3.94[2.19-7.11]; P < 0.01) were associated with delirium. In multivariable analysis, postoperative pulmonary complications were associated with moderate-deep sedation (OR, 2.14[1.18-3.87]; P = 0 .01) but not with CI (OR, 1.49 [0.76-2.92]; P = 0 .25). CONCLUSIONS Cognitive impairment was associated with higher rates of moderate-deep residual sedation during anesthesia recovery and delirium, while moderate-deep sedation was associated with higher rates of pulmonary complications and delirium. We speculate that tailoring the anesthetic to facilitate faster emergence for CI patients could improve complication rates.
Collapse
Affiliation(s)
- S Chandralekha Kruthiventi
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Atousa Deljou
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - David S Knopman
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Ronald C Petersen
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darrell R Schroeder
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine (Drs. Kruthiventi, Laporta, Deljou, Sprung, and Weingarten), Department of Neurology (Drs. Knopman and Petersen), and Division of Biomedical Statistics and Informatics (Mr. Schroeder), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| |
Collapse
|
35
|
McCann A, Sorensen J, Nally D, Kavanagh D, McNamara DA. Discharge outcomes among elderly patients undergoing emergency abdominal surgery: registry study of discharge data from Irish public hospitals. BMC Geriatr 2020; 20:72. [PMID: 32075577 PMCID: PMC7031938 DOI: 10.1186/s12877-020-1469-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intra-abdominal emergency surgery is associated with high mortality risk and long length of hospital stay. The objective of this study was to explore variations in surgery rates, the relationship between admission source and discharge destination, and whether the postoperative length of stay was related to nursing home capacity in Irish counties. METHODS Data on emergency hospital episodes for 2014-18 for patients aged over 65 years with a primary abdominal procedure code were obtained from the National Quality Assurance Improvement System. Data on population and nursing home capacity were obtained from the Central Statistics Office and the Health Information and Quality Authority. Episode rates per 100,000 were estimated for sex and age groups and compared between 26 Irish counties. The association between admission source and discharge destination was explored in terms episode numbers, length of stay and mortality. A negative binomial regression model estimated casemix adjusted excess post-operative length of stay. The correlation between excess post-operative length of stay and nursing home capacity was explored by linear regression. RESULTS Overall, 4951 hospital episodes were included. The annual surgery rate ranged from 100 episodes per 100,000 65-69 years old to 250 per 100,000 85-89 year old men. 90% of the episodes were admitted from patients' home. Four in five of these patients returned to their home while 12.7% died at hospital. The proportion of episodes where patients returned to their home reduced to two in five for those aged 85-89 years. The post-operative length of stay was 13.6 days longer (p < 0.01) for episodes admitted from home and discharged to nursing home in comparison with episodes discharged home. A negative association (p = 0.08) was found between excess post-operative length of stay and county-level nursing home capacity. CONCLUSIONS This study provides relevant information to support informed consent to surgery for patients and clinicians and to improve the provision of care to older patients presenting with intra-abdominal emergencies.
Collapse
Affiliation(s)
- Aisling McCann
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, 2 Proud’s Lane, Dublin, Ireland
| | - Jan Sorensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Beaux Lane House, Mercer Street Lower, Dublin, Ireland
| | - Deirdre Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121 St. Stephen’s Green, Dublin, Ireland
| | - Dara Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121 St. Stephen’s Green, Dublin, Ireland
| | - Deborah A. McNamara
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, 2 Proud’s Lane, Dublin, Ireland
| |
Collapse
|
36
|
Abstract
As the population ages, there is a higher prevalence of both dementia and conditions that require major surgery. However, patients with dementia undergoing surgery have poorer outcomes than surgical patients without dementia. This article explores new guidance about delivering perioperative care for patients with dementia presenting for surgery. Management of patients with cognitive changes begins with developing an understanding of the classifications and pathophysiology of these disease processes, and addressing any modifiable risk factors for developing dementia, postoperative cognitive decline and postoperative delirium. Thorough preoperative assessment provides the opportunity to identify patients with and at risk of these cognitive impairments and to involve the appropriate multidisciplinary team in care planning. Once patients are identified, an individualised perioperative management plan addressing any issues surrounding capacity and consent, conduct of anaesthesia, possible polypharmacy and potential drug interactions, and postoperative pain management can improve quality of care and outcomes for these patients.
Collapse
Affiliation(s)
| | - Helen Jordan
- South East Scotland School of Anaesthesia, Edinburgh, Scotland
| | - Annemarie B Docherty
- Department of Anaesthesia and Critical Care, University of Edinburgh, Edinburgh, Scotland Conflicts of interest
| |
Collapse
|
37
|
Shia BC, Qin L, Lin KC, Fang CY, Tsai LL, Kao YW, Wu SY. Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study. Cancer Med 2019; 9:562-574. [PMID: 31789464 PMCID: PMC6970054 DOI: 10.1002/cam4.2730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022] Open
Abstract
Background To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy. Methods We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index. Results We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores. Conclusions Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.
Collapse
Affiliation(s)
- Ben-Chang Shia
- Research Center of Big Data, College of management, Taipei Medical University, Taipei, Taiwan.,College of Management, Taipei Medical University, Taipei, Taiwan.,Executive Master Program of Business Administration in Biotechnology, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Lei Qin
- School of Statistics, University of International Business and Economics, Beijing, China
| | - Kuan-Chou Lin
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Yuan Fang
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Lo-Lin Tsai
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Wei Kao
- Graduate Institute of Business Administration, Fu Jen Catholic University, Taipei, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.,Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.,Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
38
|
Dementia is associated with increased mortality and poor patient-centered outcomes after vascular surgery. J Vasc Surg 2019; 71:1685-1690.e2. [PMID: 31703830 DOI: 10.1016/j.jvs.2019.07.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/04/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Dementia has been associated with increased complications and mortality in orthopedics and other surgical specialties, but has received limited attention in vascular surgery. Therefore, we evaluated the association of dementia with surgical outcomes for elderly patients with Medicare who underwent a variety of open and percutaneous vascular surgery procedures. METHODS We reviewed claims data from the Centers for Medicare and Medicaid Services for beneficiaries enrolled in Medicare Part A fee-for-service insurance from January 1, 2011, to December 31, 2011, who underwent inpatient vascular surgery. Only the first surgery during the first admission was considered for analysis. Traditional outcomes (30- and 90-day mortality, intensive care admission, complications, length of stay) and patient-centered outcomes (discharge to home, extended skilled nursing facility [SNF] stay, time at home) were adjusted for patient and procedure characteristics using multilevel linear or logistic regression as appropriate. All analyses were performed using SAS (v9.4, SAS Institute Inc, Cary, NC). RESULTS Our study included 210,918 patients undergoing vascular surgery, of whom 27,920 carried a diagnosis of dementia. The average age of the entire cohort was 75.74 years, and 55.43% were male. Patients with dementia were older and had higher rates of comorbidities compared with patients without a dementia diagnosis. The three most common defined classes of intervention excluding miscellaneous ones were cerebrovascular, peripheral arterial, and aortic cases, which jointly accounted for 53.15% of cases. Among all cases, 56.62% were open. Emergent/urgent cases were more frequent amongst those with dementia (60.66% vs 37.93%; P < .001). After adjustment, patients with dementia had increased odds of 30-day mortality (odds ratio [OR], 1.21; P < .0001) and 90-day mortality (OR, 1.63; P < .0001), extended SNF stay (OR, 3.47; P < .0001), and longer hospital length of stay (8.29 days vs 5.41 days; P < .001). They were less likely to be discharged home (OR, 0.31; P < .0001) and spent a lower fraction of time at home after discharge (63.29% vs 86.91%; P < .001). Intensive care admission and inpatient complications were similar between the two groups. CONCLUSIONS Dementia is associated with poor traditional outcomes, including increased 30- and 90-day mortality and longer hospital lengths of stay in this large national patient sample. It is also associated with worse patient-centered outcomes, including substantially lower discharge rates to home, less time spent at home after discharge, and higher rates of extended stay in a SNF. These data should be used to counsel patients facing vascular surgery to provide goal-concordant care, particularly to patients with dementia.
Collapse
|
39
|
Kotera A. Geriatric Nutritional Risk Index and Controlling Nutritional Status Score can predict postoperative 180-day mortality in hip fracture surgeries. JA Clin Rep 2019; 5:62. [PMID: 32026110 PMCID: PMC6967303 DOI: 10.1186/s40981-019-0282-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/09/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The Geriatric Nutritional Risk Index (GNRI) based on serum albumin level and body weight and the Controlling Nutritional Status Score (CONUT) based on serum albumin level, total cholesterol level, and total lymphocyte count were created to evaluate objectively a patient's nutritional status in 2005. Here we validated the usefulness of the GNRI and the CONUT as a prognostic factor of the 180-day mortality in patients who underwent hip fracture surgeries. We retrospectively collected data from patients with hip surgeries performed from January 2012 to December 2018. The variables required for the GNRI and the CONUT and the factors presumably associated with postoperative mortality including the patients' characteristics were collected from the medical charts. Intergroup differences were assessed with the χ2 test with Yates' correlation for continuity in category variables. The Mann-Whitney U test was used to test for differences in continuous variables. We validated the power of the GNRI and the CONUT values to distinguish patients who died ≤ 180 days post-surgery from those who did not, by calculating the area under the receiver operating characteristic curve (AUC). The correlation between these two models was analyzed by Spearman's rank correlation (ρ). RESULTS We retrospectively examined the cases of 607 patients aged 87 ± 6 (range 70-102) years old. The 180-day mortality rate was 5.4% (n = 33 non-survivors). The GNRI value in the non-survivors was 83 ± 9 (range 66-111), which was significantly lower than that in the survivors at 92 ± 9 (range 64-120). The CONUT value in the non-survivors was 6 ± 3 (range 1-11), which was significantly higher than that in the survivors at 4 ± 2 (range 0-11). The AUC value to predict the 180-day mortality was 0.74 for the GNRI and 0.72 for the CONUT. The ρ value between these two models was 0.61 in the total of 607 patients and was 0.78 in the 33 non-survivors. CONCLUSIONS Our results suggest that the GNRI and the CONUT are a simple and useful tool to predict the 180-day mortality in patients who have undergone a hip surgery.
Collapse
Affiliation(s)
- Atsushi Kotera
- Department of Anesthesiology, Kumamoto Central Hospital, 955 Muro, Ozu-machi Kikuchi-gun, Kumamoto, 869-1235, Japan.
| |
Collapse
|
40
|
George EL, Chen R, Trickey AW, Brooke BS, Kraiss L, Mell MW, Goodney PP, Johanning J, Hockenberry J, Arya S. Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms. J Vasc Surg 2019; 71:46-55.e4. [PMID: 31147116 DOI: 10.1016/j.jvs.2019.01.074] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database. METHODS Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year. RESULTS A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001). CONCLUSIONS There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.
Collapse
Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
| | - Rui Chen
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, Calif
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, Calif
| | | | - Larry Kraiss
- Division of Vascular Surgery, University of Utah, Salt Lake, Utah
| | - Matthew W Mell
- Division of Vascular and Endovascular Surgery, University of California Davis, Sacramento, Calif
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jason Johanning
- Division of Vascular Surgery, University of Nebraska, Lincoln, Neb
| | | | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif; Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, Calif.
| |
Collapse
|
41
|
Cao SJ, Chen D, Yang L, Zhu T. Effects of an abnormal mini-mental state examination score on postoperative outcomes in geriatric surgical patients: a meta-analysis. BMC Anesthesiol 2019; 19:74. [PMID: 31092206 PMCID: PMC6521510 DOI: 10.1186/s12871-019-0735-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background Perioperative cognitive impairment (CI) following surgeries is prevalent in geriatric surgical population aged 60 and older. This meta-analysis was designed to investigate whether the Mini-Mental State Examination (MMSE) has prognostic value on adverse outcomes in aged surgical patients. Methods PubMed, Cochrane, Embase and Medline through the Ovid were searched. Meta-analyses were carried out for CI versus non-cognitive impairment (NCI). Quality of evidence was assessed by the GRADE approach. Results One randomized controlled trial, two retrospective cohort trials, and 18 prospective cohort trials were included in the meta-analysis. Perioperative diagnosis of CI by the MMSE had higher rates of patients suffering from postoperative delirium (POD) [odd ratio (OR) 5.02, 95% confidence interval (CI) 3.27, 7.71, P < 0.00001], in-hospital mortality (OR 7.51, 95% CI 2.17, 26.02, P = 0.001), mortality within 1 year (OR 2.53, 95% CI 1.95,3.29, P < 0.00001). Postoperative CI patients had no extended length of stay in orthopedic [standardized mean difference (SMD) -0.10, 95% CI -0.20, 0.17, P = 0.91)] nor rehabilitation wards ((SMD, 0.04; 95% CI, − 0.23 to 0.31; P = 0.78). Conclusion Older patients with perioperative CI were more likely to suffer from POD and mortality. The MMSE showed certain value on risk stratification and prognosis evaluation in geriatric surgical population. Trial registration PROSPERO CRD42018108739. Electronic supplementary material The online version of this article (10.1186/s12871-019-0735-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Shuang-Jiao Cao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Dongxu- Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Lei Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
| |
Collapse
|
42
|
Yen CC, Liu MY, Chen PW, Hung PH, Su TH, Hsu YH. Prehemodialysis arteriovenous access creation is associated with better cardiovascular outcomes in patients receiving hemodialysis: a population-based cohort study. PeerJ 2019; 7:e6680. [PMID: 30976467 PMCID: PMC6451437 DOI: 10.7717/peerj.6680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/21/2019] [Indexed: 11/20/2022] Open
Abstract
Background Cardiovascular (CV) disease contributes to nearly half of the mortalities in patients with end-stage renal disease. Patients who received prehemodialysis arteriovenous access (pre-HD AVA) creation had divergent CV outcomes. Methods We conducted a population-based cohort study by recruiting incident patients receiving HD from 2001 to 2012 from the Taiwan National Health Insurance Research Database. Patients’ characteristics, comorbidities, and medicines were analyzed. The primary outcome of interest was major adverse cardiovascular events (MACEs), defined as hospitalization due to acute myocardial infarction, stroke, or congestive heart failure (CHF) occurring within the first year of HD. Secondary outcomes included MACE-related mortality and all-cause mortality in the same follow-up period. Results The patients in the pre-HD AVA group were younger, had a lower burden of underlying diseases, were more likely to use erythropoiesis-stimulating agents but less likely to use renin–angiotensin–aldosterone system blockers. The patients with pre-HD AVA creation had a marginally lower rate of MACEs but a significant 35% lower rate of CHF hospitalization than those without creation (adjusted hazard ratio (HR) 0.65, 95% confidence interval (CI) [0.48–0.88]). In addition, the pre-HD AVA group exhibited an insignificantly lower rate of MACE-related mortality but a significantly 52% lower rate of all-cause mortality than the non-pre-HD AVA group (adjusted HR 0.48, 95% CI [0.39–0.59]). Sensitivity analyses obtained consistent results. Conclusions Pre-HD AVA creation is associated with a lower rate of CHF hospitalization and overall death in the first year of dialysis.
Collapse
Affiliation(s)
- Cheng-Chieh Yen
- Division of Nephrology, Department of Internal Medicine, Ditmansion Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan
| | - Mei-Yin Liu
- Health Center, Municipal Jingliau Junior High School, Tainan City, Taiwan
| | - Po-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Peir-Haur Hung
- Division of Nephrology, Department of Internal Medicine, Ditmansion Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan
| | - Tse-Hsuan Su
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan City, Taiwan
| | - Yueh-Han Hsu
- Division of Nephrology, Department of Internal Medicine, Ditmansion Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung City, Taiwan.,Department of Nursing, Min-Hwei College of Health Care Management, Tainan City, Taiwan
| |
Collapse
|
43
|
Predicting 90-Day Mortality in Locoregionally Advanced Head and Neck Squamous Cell Carcinoma after Curative Surgery. Cancers (Basel) 2018; 10:cancers10100392. [PMID: 30360381 PMCID: PMC6210656 DOI: 10.3390/cancers10100392] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/13/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose: To propose a risk classification scheme for locoregionally advanced (Stages III and IV) head and neck squamous cell carcinoma (LA-HNSCC) by using the Wu comorbidity score (WCS) to quantify the risk of curative surgeries, including tumor resection and radical neck dissection. Methods: This study included 55,080 patients with LA-HNSCC receiving curative surgery between 2006 and 2015 who were identified from the Taiwan Cancer Registry database; the patients were classified into two groups, mortality (n = 1287, mortality rate = 2.34%) and survival (n = 53,793, survival rate = 97.66%), according to the event of mortality within 90 days of surgery. Significant risk factors for mortality were identified using a stepwise multivariate Cox proportional hazards model. The WCS was calculated using the relative risk of each risk factor. The accuracy of the WCS was assessed using mortality rates in different risk strata. Results: Fifteen comorbidities significantly increased mortality risk after curative surgery. The patients were divided into low-risk (WCS, 0–6; 90-day mortality rate, 0–1.57%), intermediate-risk (7–11; 2.71–9.99%), high-risk (12–16; 17.30–20.00%), and very-high-risk (17–18 and >18; 46.15–50.00%) strata. The 90-day survival rates were 98.97, 95.85, 81.20, and 53.13% in the low-, intermediate-, high-, and very-high-risk patients, respectively (log-rank p < 0.0001). The five-year overall survival rates after surgery were 70.86, 48.62, 22.99, and 18.75% in the low-, intermediate-, high-, and very-high-risk patients, respectively (log-rank p < 0.0001). Conclusion: The WCS is an accurate tool for assessing curative-surgery-related 90-day mortality risk and overall survival in patients with LA-HNSCC.
Collapse
|