Abstract：
OBJECTIVE: Cirrhosis patients are at increased risk for postoperative complications. It remains unclear whether preoperative nonsurgical clinician visits improve postoperative outcomes. We assessed the impact of preoperative primary care physician (PCP) and/or Gastroenterologist/Hepatologist (GI/Hep) visits on postoperative mortality in cirrhosis patients undergoing surgery and explored differences in medication changes and paracentesis rates as potential mediators.
METHODS: This was a retrospective cohort study of cirrhosis patients in the Veterans Health Administration who underwent surgery between 2008 and 2016. We compared 1982 patients with preoperative PCP and/or GI/Hep visits with 1846 propensity matched patients without preoperative visits. We used Cox regression and Fine and Gray competing risk regression to evaluate the association between preoperative visit type and postoperative mortality at 6 months.
RESULTS: Patients with preoperative GI/Hep and PCP visits had a 45% lower hazard of postoperative mortality compared to those without preoperative visits (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.35-0.87). A smaller effect size was noted with GI/Hep preoperative visit alone (HR, 0.69; 95% CI, 0.48-0.99) or PCP visit alone (HR, 0.70; 95% CI, 0.53-0.93). Patients with preoperative PCP/GI/Hep visits were more likely to have diuretics, spontaneous bacterial peritonitis prophylaxis, and hepatic encephalopathy medications newly initiated and/or dose adjusted and more likely to receive preoperative paracentesis as compared to those without preoperative visits.
CONCLUSIONS: Preoperative PCP/GI/Hep visits are associated with a reduced risk of postoperative mortality with the greatest risk reduction observed in those with both PCP and GI/Hep visits. This synergistic effect highlights the importance of a multidisciplinary approach in the preoperative care of cirrhosis patients.
METHODS: This was a retrospective cohort study of cirrhosis patients in the Veterans Health Administration who underwent surgery between 2008 and 2016. We compared 1982 patients with preoperative PCP and/or GI/Hep visits with 1846 propensity matched patients without preoperative visits. We used Cox regression and Fine and Gray competing risk regression to evaluate the association between preoperative visit type and postoperative mortality at 6 months.
RESULTS: Patients with preoperative GI/Hep and PCP visits had a 45% lower hazard of postoperative mortality compared to those without preoperative visits (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.35-0.87). A smaller effect size was noted with GI/Hep preoperative visit alone (HR, 0.69; 95% CI, 0.48-0.99) or PCP visit alone (HR, 0.70; 95% CI, 0.53-0.93). Patients with preoperative PCP/GI/Hep visits were more likely to have diuretics, spontaneous bacterial peritonitis prophylaxis, and hepatic encephalopathy medications newly initiated and/or dose adjusted and more likely to receive preoperative paracentesis as compared to those without preoperative visits.
CONCLUSIONS: Preoperative PCP/GI/Hep visits are associated with a reduced risk of postoperative mortality with the greatest risk reduction observed in those with both PCP and GI/Hep visits. This synergistic effect highlights the importance of a multidisciplinary approach in the preoperative care of cirrhosis patients.
摘要：
目的：肝硬化患者术后并发症的风险增加。目前尚不清楚术前非手术临床医师访视是否能改善术后预后。我们评估了术前初级保健医师（PCP）和/或胃肠病学家/肝病学家（GI/Hep）访视对肝硬化患者手术后死亡率的影响，并探讨了药物变化和穿刺率作为潜在介质的差异。
方法：这是退伍军人健康管理局在2008年至2016年间接受手术的肝硬化患者的回顾性队列研究。我们比较了1982例术前PCP和/或GI/Hep就诊的患者与1846例没有术前就诊的倾向匹配的患者。我们使用Cox回归和Fine和Gray竞争风险回归来评估术前就诊类型与术后6个月死亡率之间的关系。
结果：术前GI/Hep和PCP访视的患者与未术前访视的患者相比，术后死亡率降低了45％（风险比[HR]，0.55；95%置信区间[CI]，0.35-0.87）。单独使用GI/Hep术前访视观察到较小的效应大小(HR，0.69；95%CI，0.48-0.99）或单纯PCP访视（HR，0.70；95%CI，0.53-0.93）。术前PCP/GI/Hep就诊的患者更有可能使用利尿剂，自发性细菌性腹膜炎的预防，和肝性脑病药物新开始和/或剂量调整，与没有术前访视的患者相比，更有可能接受术前穿刺。
结论：术前PCP/GI/Hep访视与术后死亡风险降低相关，其中PCP和GI/Hep访视的风险降低最大。这种协同效应突出了多学科方法在肝硬化患者术前护理中的重要性。
方法：这是退伍军人健康管理局在2008年至2016年间接受手术的肝硬化患者的回顾性队列研究。我们比较了1982例术前PCP和/或GI/Hep就诊的患者与1846例没有术前就诊的倾向匹配的患者。我们使用Cox回归和Fine和Gray竞争风险回归来评估术前就诊类型与术后6个月死亡率之间的关系。
结果：术前GI/Hep和PCP访视的患者与未术前访视的患者相比，术后死亡率降低了45％（风险比[HR]，0.55；95%置信区间[CI]，0.35-0.87）。单独使用GI/Hep术前访视观察到较小的效应大小(HR，0.69；95%CI，0.48-0.99）或单纯PCP访视（HR，0.70；95%CI，0.53-0.93）。术前PCP/GI/Hep就诊的患者更有可能使用利尿剂，自发性细菌性腹膜炎的预防，和肝性脑病药物新开始和/或剂量调整，与没有术前访视的患者相比，更有可能接受术前穿刺。
结论：术前PCP/GI/Hep访视与术后死亡风险降低相关，其中PCP和GI/Hep访视的风险降低最大。这种协同效应突出了多学科方法在肝硬化患者术前护理中的重要性。
