术前「衰弱筛检倡议」可降低死亡率


  【24drs.com】根据在线发表于11月30日JAMA Surgery期刊的一篇世代研究,实施「衰弱筛检倡议(Frailty Screening Initiative,FSI)」可降低年长患者的术后死亡率。
  
  宾州匹兹堡退伍军人事务健康照护体系Daniel E. Hall医师等人写道,衰弱患者的180天死亡率绝对降低幅度超过19%,即便是控制年龄、衰弱程度和预测死亡率之后,改善成效依旧显著。
  
  研究者评估了在2007年10月1日至2014年7月1日间进行选择性、非心脏外科手术的9,153名患者的资料,这些患者的平均年龄为60.3岁,大部份是男性。
  
  风险分析指数(RAI)这项14点问卷的开发与测试,始于2010年7月,2011年1月开始配置于医院,2011年7月充分实施。作者们指出,安排手术时要求进行RAI评分,在选择性手术方面获得将近100%的遵从率。
  
  患者在入院时进行衰弱筛检,6.8%被视为衰弱(RAI分数≧21),作者们指出,实施此计画前后,依据病患人口统计学与美国麻醉科医师协会,视为虚弱之患者的比率相当,实施衰弱筛检之后,由外科、麻醉、重症照护和安宁照护医师评估后,根据需要而改变手术计画和手术前后期间的照护。
  
  作者们发现,实施FSI之后,整体的30天死亡率从1.6% (84/5275)降低到0.7% (26/3878)(P < .001),采用FSI对于衰弱患者的死亡率有最大的影响,从12.2% (24/197)降低到3.8%(16/424; P < .001);不过,健壮者的死亡率也降低,从1.2% (60/5078)降低到0.3% (10/3454; P < 0.001)。
  
  研究者也指出,术后180天的死亡率也有改善,从23.9% (47/197)降低到7.7% (30/389; P < .001),术后365天时也是,从34.5%(68/197)降低到11.7% (36/309; P < .001)。
  
  Hall医师等人写道,本研究发现,在选择性手术人口中进行设施范围内虚弱筛检的可行性。另外也认为,透过系统性住院筛检、审查、以及优化手术前后相关计画,可改善虚弱者的术后存活。
  
  此外,研究者使用控制年龄与RAI分数之多变项模式,评估实施FSI与衰弱之间的相互影响,他们指出,虽然这个相互影响对于预测30天死亡率并不显著(P = .66),它可以预测180天与365天时的存活(分别是P = .02与P = .01)。作者们强调,这项结果也认为,需要30天以上来测得这些介入的影响,进一步描述了其它研究指出的30天结果的局限性。
  
  研究作者承认,在虚弱者和健壮者之所以都有改善,可能是霍桑效应之影响,因为较差的手术候选人可能已经被排除于接受手术。
  
  在受邀评论中,来自加州大学旧金山分校的Anne M. Suskind医师与Emily Finlayson医师指出,虚弱性评估在术前环境中越来越重要,但是也提醒,将余命有限的患者排除于手术介入,或许可以改善出自于对不佳死亡率统计之恐惧的症状处置才是真正考量。
  
  评论者指出,术前计画应聚焦于患者个人的照护目标,这不一定会包括手术。
  
  Suskind医师与Finlayson医师结论指出,至少,将术前虚弱评估作为建立个人整体手术适合性的门槛,并使外科医师除了手边的外科问题之外还考虑全人。
  
  Hall医师等人在另一篇文献报告RAI评分之开发与初步确效,在线发表于11月23日JAMA Surgery期刊,完整的RAI问卷登载于该文的补充资料。
  
  资料来源:http://www.24drs.com/
  
  Native link:Preoperative Frailty Screening Initiative Reduces Mortality

Preoperative Frailty Screening Initiative Reduces Mortality

By Jennifer Garcia
Medscape Medical News

Implementation of a Frailty Screening Initiative (FSI) appears to reduce postoperative mortality among elderly patients, according to a cohort study published online November 30 in JAMA Surgery.

"The absolute reduction in 180-day mortality among frail patients was more than 19%, with improvement remaining robust even after controlling for age, frailty, and predicted mortality," write Daniel E. Hall, MD, MDiv, MHSc, from the Veterans Affairs Pittsburgh Healthcare System, Pennsylvania, and colleagues.

The researchers evaluated data from 9153 patients undergoing elective, noncardiac surgical procedures between October 1, 2007, and July 1, 2014. The mean age of patients was 60.3 years, and the majority were male.

Development and testing of the Risk Analysis Index (RAI), which is a 14-point questionnaire, started in July 2010, and deployment at the hospital was started in January 2011, with full implementation in July 2011. The authors note that an RAI score was required during surgical scheduling, which led to a near 100% adherence for elective surgeries.

Patients were screened for frailty at intake, and 6.8% were deemed as frail (RAI score ? 21). The authors note that the proportion of patients deemed frail before and after implementation were similar, as were patient demographics and American Society of Anesthesiologists classification. After implementation of the frailty screening, changes to surgical planning and perioperative care were instituted as needed after review by clinicians from surgery, anesthesia, critical care, and palliative care.

The authors found that overall 30-day mortality decreased from 1.6% (84/5275) to 0.7% (26/3878) after FSI implementation (P < .001). Use of the FSI appeared to have the greatest effect on mortality rate among frail patients, going from 12.2% (24/197) to 3.8% (16/424; P < .001); however, mortality rates decreased among robust patients as well, going from 1.2% (60/5078) to 0.3% (10/3454; P < 0.001).

The researchers also noted improvements at 180 days postoperatively, going from 23.9% (47/197) to 7.7% (30/389; P < .001), and 365 days postoperatively, going from 34.5% (68/197) to 11.7% (36/309; P < .001).

"This study reveals the feasibility of facility-wide frailty screening in elective surgical populations," write Dr. Hall and colleagues. "It also suggests the potential to improve postoperative survival among the frail through systematic administrative screening, review, and optimization of perioperative plans."

In addition, the researchers used a multivariable model that controlled for age and RAI score and evaluated the interaction between FSI implementation and frailty. They noted that although the interaction was not a significant predictor of mortality at 30 days (P = .66), it did predict survival at 180 and 365 days (P = .02 and P = .01, respectively). The authors underscore that "[t]his finding also suggests that it takes more than 30 days to detect the effect of these interventions, further delineating the limitations of 30-day outcomes noted by others."

The study authors acknowledge that the Hawthorne effect may have played a role in why improvements were noted in both frail as well as robust patients, as poor operative candidates may have been excluded from undergoing surgery.

In an invited commentary, Anne M. Suskind, MD, and Emily Finlayson, MD, both from the University of California, San Francisco, acknowledge the increasing importance of frailty assessment in the preoperative setting, but caution that "[e]xcluding patients with limited life expectancy from surgical interventions that may improve symptom management out of fear of poor mortality statistics is a real concern."

The commentators note that preoperative planning should be undertaken with a focus "on the patient's individual goals of care, which may not always include surgery."

"At the very least, preoperative frailty assessment serves as a portal into the overall surgical fitness of an individual and leads the surgeon to consider the whole person in addition to the surgical problem at hand," conclude Dr. Suskind and Dr. Finlayson.

Dr Hall and colleagues report the development and initial validation of the RAI score in a separate article, published online November 23 in JAMA Surgery. The full RAI questionnaire is available as a supplement to that article.

Funding for this study was provided through a grant from the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development. The authors and commentators have disclosed no relevant financial relationships.

JAMA Surg. Published online November 30, 2016.

    
相关报导
低BMI与术后30天死亡率较高有关
2011/11/24 上午 11:30:14

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