術前「衰弱篩檢倡議」可降低死亡率


  【24drs.com】根據線上發表於11月30日JAMA Surgery期刊的一篇世代研究,實施「衰弱篩檢倡議(Frailty Screening Initiative,FSI)」可降低年長患者的術後死亡率。
  
  賓州匹茲堡退伍軍人事務健康照護體系Daniel E. Hall醫師等人寫道,衰弱患者的180天死亡率絕對降低幅度超過19%,即便是控制年齡、衰弱程度和預測死亡率之後,改善成效依舊顯著。
  
  研究者評估了在2007年10月1日至2014年7月1日間進行選擇性、非心臟外科手術的9,153名患者的資料,這些患者的平均年齡為60.3歲,大部份是男性。
  
  風險分析指數(RAI)這項14點問卷的開發與測試,始於2010年7月,2011年1月開始配置於醫院,2011年7月充分實施。作者們指出,安排手術時要求進行RAI評分,在選擇性手術方面獲得將近100%的遵從率。
  
  患者在入院時進行衰弱篩檢,6.8%被視為衰弱(RAI分數≧21),作者們指出,實施此計畫前後,依據病患人口統計學與美國麻醉科醫師協會,視為虛弱之患者的比率相當,實施衰弱篩檢之後,由外科、麻醉、重症照護和安寧照護醫師評估後,根據需要而改變手術計畫和手術前後期間的照護。
  
  作者們發現,實施FSI之後,整體的30天死亡率從1.6% (84/5275)降低到0.7% (26/3878)(P < .001),採用FSI對於衰弱患者的死亡率有最大的影響,從12.2% (24/197)降低到3.8%(16/424; P < .001);不過,健壯者的死亡率也降低,從1.2% (60/5078)降低到0.3% (10/3454; P < 0.001)。
  
  研究者也指出,術後180天的死亡率也有改善,從23.9% (47/197)降低到7.7% (30/389; P < .001),術後365天時也是,從34.5%(68/197)降低到11.7% (36/309; P < .001)。
  
  Hall醫師等人寫道,本研究發現,在選擇性手術人口中進行設施範圍內虛弱篩檢的可行性。另外也認為,透過系統性住院篩檢、審查、以及優化手術前後相關計畫,可改善虛弱者的術後存活。
  
  此外,研究者使用控制年齡與RAI分數之多變項模式,評估實施FSI與衰弱之間的相互影響,他們指出,雖然這個相互影響對於預測30天死亡率並不顯著(P = .66),它可以預測180天與365天時的存活(分別是P = .02與P = .01)。作者們強調,這項結果也認為,需要30天以上來測得這些介入的影響,進一步描述了其他研究指出的30天結果的侷限性。
  
  研究作者承認,在虛弱者和健壯者之所以都有改善,可能是霍桑效應之影響,因為較差的手術候選人可能已經被排除於接受手術。
  
  在受邀評論中,來自加州大學舊金山分校的Anne M. Suskind醫師與Emily Finlayson醫師指出,虛弱性評估在術前環境中越來越重要,但是也提醒,將餘命有限的患者排除於手術介入,或許可以改善出自於對不佳死亡率統計之恐懼的症狀處置才是真正考量。
  
  評論者指出,術前計畫應聚焦於患者個人的照護目標,這不一定會包括手術。
  
  Suskind醫師與Finlayson醫師結論指出,至少,將術前虛弱評估作為建立個人整體手術適合性的門檻,並使外科醫師除了手邊的外科問題之外還考慮全人。
  
  Hall醫師等人在另一篇文獻報告RAI評分之開發與初步確效,線上發表於11月23日JAMA Surgery期刊,完整的RAI問卷登載於該文的補充資料。
  
  資料來源: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.

    
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低BMI與術後30天死亡率較高有關
2011/11/24 上午 11:30:14

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