RESUMO
BACKGROUND: Epidural analgesia (EA) is recommended along with general anesthesia (GA) for patients undergoing open abdominal aortic aneurysm repair (AAA) and is known to be associated with improved postoperative outcomes. This study evaluates inequities in using this superior analgesic approach and further assesses the disparities at patient and hospital levels. METHODS: A retrospective analysis was performed using the Vascular Quality Initiative database of adult patients undergoing elective open AAA repair between 2003 and 2022. Patients were grouped and analyzed based on anesthesia utilization, that is, EA + GA (Group I) and GA only (Group II). Study groups were further stratified by race, and outcomes were studied. Univariate and multivariate analyses were performed to study the impact of race on the utilization of EA with GA. A subgroup analysis was also carried out to learn the EA analgesia utilization in hospitals performing open AAA with the least to most non-White patients. RESULTS: A total of 8,940 patients were included in the study, of which EA + GA (Group I) comprised n = 4,247 (47.5%) patients, and GA (Group II) had n = 4,693 (52.5%) patients. Based on multivariate regression analysis, the odds ratio of non-White patients receiving both EA and GA for open AAA repair compared to White patients was 0.76 (95% confidence interval: 0.53-0.72, P < 0.001). Of the patients who received both EA + GA, non-White race was associated with increased length of intensive care unit stay and a longer total length of hospital stay compared to White patients. Hospitals with the lowest quintile of minorities had the highest utilization of EA + GA for all patients compared to the highest quintile. CONCLUSIONS: Non-White patients are less likely to receive the EA + GA than White patients while undergoing elective open AAA repair, demonstrating a potential disparity. Also, this disparity persists at the hospital level, with hospitals with most non-White patients having the least EA utilization, pointing toward system-wide disparities.
Assuntos
Analgesia Epidural , Anestesia Epidural , Aneurisma da Aorta Abdominal , Procedimentos Endovasculares , Humanos , Estados Unidos , Analgesia Epidural/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Anestesia Geral/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Fatores de RiscoRESUMO
BACKGROUND: Frailty has been increasingly used as a prognostic indicator for various surgical operations. Patients with peripheral arterial disease represent a cohort of population with advanced medical comorbidities. The aim of this study is to correlate the postoperative outcomes after lower extremity bypass surgery with preoperative modified frailty index (mFI). METHODS: Using 2010 American College of Surgeons National Surgical Quality Improvement Program database, patients undergoing infrainguinal arterial bypass surgery were identified. mFI with 11 variables, based on the Canadian Study of Health and Aging Frailty Index, was utilized. Based on mFI score, the patients were divided into 4 groups: group 1 (mFI score: 0-0.09), group 2 (mFI score: 0.18-0.27), group 3 (mFI score: 0.36-0.45), and group 4 (mFI score: 0.54-0.63). A bivariate and multivariate analysis was done using logistic regression analysis. RESULTS: A total of 4,704 patients (64% males and 36% females) underwent infrainguinal arterial bypass. Mean age was 67.9 ± 11.7 years. Distribution of patients based on mFI was as follows: group 1: 14.6%, group 2: 55.9%, group 3: 26.9%, and group 4: 2.6%. Increase in mFI was associated with higher mortality rates. Incidence of mortality for group 1 was 0.6%; for group 2, it was 1.4%; for group 3, it was 4%; and for group 4, it was 7.4%. Likewise, the incidence of other postoperative complications such as myocardial infarction (MI), stroke, progressive renal failure, and graft failure was significantly high among patients with high mFI scores. Following factors were associated with increased risk of mortality: high mFI score, black race, dialysis dependency, postoperative renal insufficiency, MI, and postoperative acute renal failure. CONCLUSIONS: This study demonstrates that the mFI can be used as a valuable tool to identify patients at a higher risk for developing postoperative complications after lower extremity revascularization. For patients with mFI score of 0.54-0.63, the risk of mortality and complications increases significantly. mFI can be used as a useful screening tool to identify patients who are at a high risk for developing complications.
Assuntos
Técnicas de Apoio para a Decisão , Fragilidade/diagnóstico , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Idoso Fragilizado , Fragilidade/mortalidade , Avaliação Geriátrica , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/mortalidade , Adulto JovemRESUMO
OBJECTIVE: Hospital readmissions after surgical operations are preventable and are now counted as a quality metric. Patients with peripheral arterial disease often have several serious medical comorbidities. With advancements in endovascular technology and increasing comfort level of vascular surgeons, more and more patients with peripheral arterial disease are being treated with endovascular therapy. Most of these interventions are done as same-day operations. This study retrospectively reviewed the factors associated with hospital readmission after lower extremity endovascular interventions. METHODS: This study used the 2013 endovascular repair-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and generalized 2013 general and vascular surgery Program User Files. Patient, diagnosis, and procedure characteristics of patients undergoing lower extremity endovascular surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for hospital readmission ≤30 days after surgery. RESULTS: During 2013, 1096 patients (61% men, 39% women) underwent lower extremity endovascular interventions. Indications for operations included claudication (40%), critical limb ischemia with rest pain (19%), critical limb ischemia with tissue loss (35%), and others (6%) Among these patients, 147 (13.4%) were readmitted to the hospital ≤30 days after surgery, and â¼46% of all readmissions were ≤2 weeks after the discharge The following factors had significant associations with readmission: smoking (odds ratio [OR], 0.52, 95% confidence interval [CI], 0.3-0.9), noninsulin-dependent diabetes mellitus (OR, 1.65; 95% CI, 0.9-3.2), dyspnea (OR, 1.9; 95% CI, 1-3.7), insulin-dependent diabetes mellitus (OR, 2.1; 95% CI, 1.2-3.6), body mass index >30 kg/m2 (OR, 2.5; 95% CI, 1.3-5.1), dependent functional status (OR, 2.6; 95% CI, 1.4-4.8), emergent surgery (OR, 4.3; 95% CI, 1.9-9.6), and unplanned return to the operating room (OR, 8.3; 95% CI, 4.7-14.7). CONCLUSIONS: Readmission after lower extremity endovascular intervention is a serious complication. Various factors place a patient at a high risk for readmission. High body mass index, unplanned return to the operating room, insulin-dependent diabetes mellitus, noninsulin-dependent diabetes mellitus, nonsmoking status, dyspnea, dependent functional status, and emergency operation are independent risk factors for hospital readmission. Return to operating room is associated with an 8.3-fold increase in hospital readmission.