背景:由于多种因素,肝硬化患者术后并发症的风险增加,包括门静脉高压和止血改变。围手术期管理和风险分层评分的改善有助于改善预后,但是我们对接受手术的肝硬化患者的成本和发病率的理解仍然存在差距。
方法:我们于2007年1月1日至2017年12月31日使用IBM电子健康记录(EHR)MarketScan商业索赔(MSCC)数据库进行了一项病例对照研究。接受手术的非酒精性肝硬化患者根据国际疾病分类进行鉴定,第九修订版(ICD-9)/第十修订版(ICD-10)编码多个手术类别,并与在此期间未接受手术的肝硬化对照相匹配。共有115,512名患者被确定为肝硬化,其中19,542人(16.92%)接受了手术。收集了病史和合并症,对匹配组之间的手术后6个月的结局进行分析.根据索赔数据进行了成本分析。
结果:与对照组相比,接受手术的非酒精性肝硬化患者在基线时的共病指数更高(1.34vs.0.88,P<0.0001)。手术组的死亡率增加(4.68%vs.2.38%,随访期间P<0.001)。手术组有较高的不良肝脏结局的发生率,包括肝性脑病(5.00%vs.2.50%,P<0.0001),自发性细菌性腹膜炎(0.64%vs.0.25%,P<0.001),脓毒性休克的发生率更高(0.66%vs.0.14%,P<0.001),脑出血(0.49%vs.0.04%,P<0.001),和急性低氧性呼吸衰竭(7.02%vs.2.31%,P<0.001)。医疗保健利用分析显示,手术队列中每名患者的总索赔额增加(38.11vs.28.64,P<0.0001),住院率较高(6.05vs.2.35,P<0.0001),更多的门诊就诊(19.72vs.15.23,P<0.0001),和每位患者的处方索赔(11.76vs.术后10.61,P<0.0001)。在手术队列中,至少有一次住院的可能性更高(51.63%vs.22.32%,P<0.0001),住院时间更长(4.99天vs.2.09天,P<0.0001)。接受手术的患者在术后期间,每位患者的医疗服务总费用显着增加($58,246vs.$26,842,P<0.0001),主要是由于住院费用增加(34,446美元与$10,789,P<0.0001)。
结论:接受手术的非酒精性肝硬化患者在不良肝事件和并发症方面的预后较差,包括感染性休克和脑出血。索赔和成本分析显示,手术组的卫生支出显着增加,主要是由于更频繁和更长时间的住院费用。
BACKGROUND: Patients with cirrhosis are at increased risk of complications following surgery due to multiple factors, including portal hypertension and alterations in hemostasis. Improvements in perioperative management as well as risk stratification scores have helped improve outcomes, but gaps remain in our understanding of the cost and morbidity of cirrhotic patients who undergo surgery.
METHODS: We conducted a case-control study using the IBM Electronic Health Record (EHR) MarketScan Commercial Claims (MSCC) database from January 1, 2007 to December 31, 2017. Nonalcoholic cirrhotic patients who underwent surgery were identified based on International Classification of Diseases, Ninth Revision (ICD-9)/Tenth Revision (ICD-10) codes for multiple surgical categories and matched with controls with cirrhosis who did not undergo surgery in this time period. A total of 115,512 patients were identified with cirrhosis, of whom 19,542 (16.92%) had surgery. Medical history and comorbidities were compiled, and outcomes in the six-month period following surgery were analyzed between matched groups. A cost analysis was performed based on claims data.
RESULTS: Nonalcoholic cirrhotic patients who underwent surgery had a higher comorbidity index at baseline compared with controls (1.34 vs. 0.88, P<0.0001). Mortality was increased in the surgery group (4.68% vs. 2.38%, P<0.001) in the follow-up period. The surgical cohort had higher rates of adverse hepatic outcomes, including hepatic encephalopathy (5.00% vs. 2.50%, P<0.0001), spontaneous bacterial peritonitis (0.64% vs. 0.25%, P<0.001), and higher rates of septic shock (0.66% vs. 0.14%, P<0.001), intracerebral hemorrhage (0.49% vs. 0.04%, P<0.001), and acute hypoxemic respiratory failure (7.02% vs. 2.31%, P<0.001). Healthcare utilization analysis revealed increased total claims per patient in the surgical cohort (38.11 vs. 28.64, P<0.0001), higher inpatient admissions (6.05 vs. 2.35, P<0.0001), more outpatient visits (19.72 vs. 15.23, P<0.0001), and prescription claims per patient (11.76 vs. 10.61, P<0.0001) in the postsurgical period. The likelihood of at least one inpatient stay was higher in the surgical cohort (51.63% vs. 22.32%, P<0.0001), and inpatient stays were longer (4.99 days vs. 2.09 days, P<0.0001). The total cost of health services was significantly increased per patient in the postoperative period for patients undergoing surgery ($58,246 vs. $26,842, P<0.0001), largely due to increased inpatient costs ($34,446 vs. $10,789, P<0.0001).
CONCLUSIONS: Nonalcoholic cirrhotics undergoing surgery experienced worse outcomes with respect to adverse hepatic events and complications, including septic shock and intracerebral hemorrhage. Claims and cost analysis showed a significant increase in health expenditure in the surgical group, largely due to the cost of more frequent and longer inpatient admissions.