The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization within the National Surgical Quality Improvement Database

Transcription

1 The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization within the National Surgical Quality Improvement Database Joseph B. Oliver, MD MPH, Amy L. Davidow, PhD, Kimberly Nester, MSN, Advaith Bongu, MD, Teri Lassiter, PhD MPH, Abdel-Kareem Beidas, MD, Urvashi Pandit MPH MBS, George Dikdan, PhD, BabuaroKoneru, MD, and Lloyd Brown, MD MS Rutgers New Jersey Medical School, Newark, NJ

2 There are no financial disclosures for this presentation

3 Introduction Chronic Liver Disease (CLD): Prevalence ~5% 1 Over 50 articles previously published 2 Single center Specific procedures investigated No comparisons to a non CLD group No analysis of healthcare resources

4 Methods NSQIP Excluded: undergoing liver procedures, had disseminated cancer, or greater than 89 years old Case defined as presence of ascites and/or esophageal varices Comparison to all others in the database without CLD Outcomes as recorded in the NSQIP database Yes/No for mortality, morbidity, reoperation, readmission LOS in days Discharge destination: Home versus any level of skilled care

5 Methods Bivariate statistics Chi squared, Fisher s exact, or Test of Trends for categorical variables Student s t test or Mann Whitney U for continuous variables. Adjusted odds ratios via multivariate logistical regression controlling for patient severity, emergency status, surgical type, and inpatient status Zero inflated Poisson utilized for Hospital LOS 3 All statistics performed using SAS 9.3

6 Patient Demographics CLD Patient Demographics (n=8202) No CLD (n=1.3mil) P value Age (mean, SD) 59.6 years (14.65) 55.6 years (16.73) <0.001 Race: White 76.4% 76.5% <0.001 Black 12.0% 9.8% Other/Unknown 11.5% 13.7% Female 46.9% 57.2% <0.001

7 Operation Details CLD No CLD P value Operative Characteristics Surgical Subspecialty: 85.5% 63.1% <0.001 General Vascular 5.5% 10.7% Orthopedic 1.2% 9.9% Gynecological 5.0% 4.6% Emergency case 44.5% 11.6% <0.001 % Inpatients at time of surgery % Undergoing general anesthesia Work Relative Value Units (mean, SD) Operative Time (mean, SD) 92.6% 64.2% < % 90.9% < (9.6) 16.6 (8.9) < mins (86.6) mins (91.6) 0.18

8 Patient Co-morbidities CLD Non-CLD Body Mass Index (mean, SD) 27.4 (7.5) 30.0 (14.1) Patient Co-morbidities Diabetes 23.4% 15.1% Congestive Heart Failure 7.0% 0.8% History of Myocardial Infarction 2.6% 0.7% Hypertension 53.9% 46.2% Current Smoker 28.5% 19.9% History of Severe Chronic Obstructive Pulmonary Disease 10.8% 4.8% Coma 1.0% 0.1% Acute renal failure 6.1% 0.5% Currently on Dialysis 9.4% 1.7% * All p<0.001

9 Adjusted Odds Ratios MORTALITY ANY COMPLICATION COMA ACUTE RENAL FAILURE BLEEDING RESPIRATORY INSUFFICIENCY SEPTIC SHOCK REINTUBATION ORGAN SPACE INFECTION RENAL INSUFFICIENCY DEEP VEIN THROMBOSIS WOUND DEHISCENCE PNEUMONIA SYSTEMIC SEPSIS UTI PULMONARY EMBOLISM DEEP WOUND INFECTION STROKE SUPERFICIAL INFECTION HEART ATTACK

10 Healthcare resource utilization Outcome CLD Non-CLD Same day discharge 5.6% 28.6% 0.58( ) Non-home discharge 34.9% 9.2% 2.19 ( ) Readmission 14.3% 7.0% 1.31 ( ) Reoperation 10.7% 3.6% 1.48 ( ) 28% increase in LOS due to CLD

11 Discussion of Results Higher Comorbidities at Baseline Highlights need for comparison group and adjustment Mortality OR 2.39 Any Morbidity OR 1.99 Highest Complications: Coma (2.13) 4 Acute Renal Failure (2.12) 5 Bleeding (2.03) Paradoxical 6 : Deep Vein Thrombosis (1.44) Association with resources

12 Recommendations Careful recognition of patients with CLD and discussion of surgery indications Medically optimize patient prior to surgery Find ways to minimize complications Discharge planning Improvements to NSQIP Capture CLD Directly Addition Surgical Complications 7,8 Utilization of Complication Severity Scoring 9,10

13 References 1. Quan, H., G.A. Parsons, and W.A. Ghali, Validity of information on comorbidity derived rom ICD-9- CCM administrative data. Med Care, (8): p de Goede, B., et al., Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review. Best Pract Res Clin Gastroenterol, (1): p Lambert, D., Zero-Inflated Poisson Regression, with an Application to Defects in Manufacturing. Technometrics, (1): p Ferenci, P., et al., Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, Hepatology, (3): p Arroyo, V., M. Guevara, and P. Ginès, Hepatorenal syndrome in cirrhosis: Pathogenesis and treatment. Gastroenterology, (6): p Gulley, D., et al., Deep vein thrombosis and pulmonary embolism in cirrhosis patients. Dig Dis Sci, (11): p Polson, J., W.M. Lee, and D. American Association for the Study of Liver, AASLD position paper: the management of acute liver failure. Hepatology, (5): p Sarin, S.K., et al., Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int, (1): p Dindo, D., N. Demartines, and P.-A. Clavien, Classification of Surgical Complications. Annals of Surgery, (2): p Slankamenac, K., et al., The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg, (1): p. 1-7.