The Impact of Functional Dependence and Related Surgical Complications on Postoperative Mortality

Overview

Journal J Med Syst

Specialty Medical Informatics

Date 2021 Nov 25

PMID 34822038

Citations 1

Authors

Jacob C Clifton

Milo Engoren

Matthew S Shotwell

Barbara J Martin

Elise M Clemens

Oscar D Guillamondegui

Robert E Freundlich

Affiliations

Soon will be listed here.

Abstract

Purpose: Functional dependency is a known determinant of surgical risk. To enhance our understanding of the relationship between dependency and adverse surgical outcomes, we studied how postoperative mortality following a surgical complication was impacted by preoperative functional dependency.

Methods: We explored a historical cohort of 6,483,387 surgical patients within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). All patients ≥ 18 years old within the ACS-NSQIP from 2007 to 2017 were included.

Results: There were 6,222,611 (96.5%) functionally independent, 176,308 (2.7%) partially dependent, and 47,428 (0.7%) totally dependent patients. Within 30 days postoperatively, 57,652 (0.9%) independent, 15,075 (8.6%) partially dependent, and 10,168 (21.4%) totally dependent patients died. After adjusting for confounders, increasing functional dependency was associated with increased odds of mortality (Partially Dependent OR: 1.72, 99% CI: 1.66 to 1.77; Totally Dependent OR: 2.26, 99% CI: 2.15 to 2.37). Dependency also significantly impacted mortality following a complication; however, independent patients usually experienced much stronger increases in the odds of mortality. There were six complications not associated with increased odds of mortality. Model diagnostics show our model was able to distinguish between patients who did and did not suffer 30-day postoperative mortality nearly 96.7% of the time.

Conclusions: Within our cohort, dependent surgical patients had higher rates of comorbidities, complications, and odds of 30-day mortality. Preoperative functional status significantly impacted the level of postoperative mortality following a complication, but independent patients were most affected.

Citing Articles

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References

Fried L, Ferrucci L, Darer J, Williamson J, Anderson G . Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004; 59(3):255-63. DOI: 10.1093/gerona/59.3.m255. View

Bien J, Taylor J, Tibshirani R . A LASSO FOR HIERARCHICAL INTERACTIONS. Ann Stat. 2015; 41(3):1111-1141. PMC: 4527358. DOI: 10.1214/13-AOS1096. View

Pel-Littel R, Schuurmans M, Emmelot-Vonk M, Verhaar H . Frailty: defining and measuring of a concept. J Nutr Health Aging. 2009; 13(4):390-4. DOI: 10.1007/s12603-009-0051-8. View

Stienen M, Zhang D, Broggi M, Seggewiss D, Villa S, Schiavolin S . The influence of preoperative dependency on mortality, functional recovery and complications after microsurgical resection of intracranial tumors. J Neurooncol. 2018; 139(2):441-448. DOI: 10.1007/s11060-018-2882-9. View

Makary M, Segev D, Pronovost P, Syin D, Bandeen-Roche K, Patel P . Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010; 210(6):901-8. DOI: 10.1016/j.jamcollsurg.2010.01.028. View

Chow W, Rosenthal R, Merkow R, Ko C, Esnaola N . Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215(4):453-66. DOI: 10.1016/j.jamcollsurg.2012.06.017. View

Shah R, Attwood K, Arya S, Hall D, Johanning J, Gabriel E . Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. JAMA Surg. 2018; 153(5):e180214. PMC: 5875343. DOI: 10.1001/jamasurg.2018.0214. View

Cohen M, Bilimoria K, Ko C, Richards K, Hall B . Effect of subjective preoperative variables on risk-adjusted assessment of hospital morbidity and mortality. Ann Surg. 2009; 249(4):682-9. DOI: 10.1097/SLA.0b013e31819eda21. View

McDonald V, Thompson K, Lewis P, Sise C, Sise M, Shackford S . Frailty in trauma: A systematic review of the surgical literature for clinical assessment tools. J Trauma Acute Care Surg. 2016; 80(5):824-34. DOI: 10.1097/TA.0000000000000981. View

10.

Cook N . Statistical evaluation of prognostic versus diagnostic models: beyond the ROC curve. Clin Chem. 2007; 54(1):17-23. DOI: 10.1373/clinchem.2007.096529. View

11.

Minhas S, Mazmudar A, Patel A . Pre-operative functional status as a predictor of morbidity and mortality after elective cervical spine surgery. Bone Joint J. 2017; 99-B(6):824-828. DOI: 10.1302/0301-620X.99B6.BJJ-2016-1149.R1. View

12.

Kaplan R, Chambers D, Glasgow R . Big data and large sample size: a cautionary note on the potential for bias. Clin Transl Sci. 2014; 7(4):342-6. PMC: 5439816. DOI: 10.1111/cts.12178. View

13.

Steyerberg E, Vickers A, Cook N, Gerds T, Gonen M, Obuchowski N . Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiology. 2009; 21(1):128-38. PMC: 3575184. DOI: 10.1097/EDE.0b013e3181c30fb2. View

14.

Groenwold R, White I, Donders A, Carpenter J, Altman D, Moons K . Missing covariate data in clinical research: when and when not to use the missing-indicator method for analysis. CMAJ. 2012; 184(11):1265-9. PMC: 3414599. DOI: 10.1503/cmaj.110977. View

15.

Hall D, Arya S, Schmid K, Blaser C, Carlson M, Bailey T . Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg. 2016; 152(2):175-182. PMC: 7140150. DOI: 10.1001/jamasurg.2016.4202. View

16.

Puts M, Lips P, Deeg D . Static and dynamic measures of frailty predicted decline in performance-based and self-reported physical functioning. J Clin Epidemiol. 2005; 58(11):1188-98. DOI: 10.1016/j.jclinepi.2005.03.008. View

17.

de la Fuente S, Bennett K, Scarborough J . Functional status determines postoperative outcomes in elderly patients undergoing hepatic resections. J Surg Oncol. 2013; 107(8):865-70. DOI: 10.1002/jso.23335. View

18.

White I, Royston P, Wood A . Multiple imputation using chained equations: Issues and guidance for practice. Stat Med. 2011; 30(4):377-99. DOI: 10.1002/sim.4067. View

19.

Lally F, Crome P . Understanding frailty. Postgrad Med J. 2007; 83(975):16-20. PMC: 2599957. DOI: 10.1136/pgmj.2006.048587. View

20.

Robinson T, Eiseman B, Wallace J, Church S, McFann K, Pfister S . Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009; 250(3):449-55. DOI: 10.1097/SLA.0b013e3181b45598. View