Long-term disease interactions amongst surgical patients: a population cohort study

Alexander J Fowler; M A Hussein Wahedally; Tom E F Abbott; John R Prowle; David A Cromwell; Rupert M Pearse

doi:10.1016/j.bja.2023.04.041

Long-term disease interactions amongst surgical patients: a population cohort study

Br J Anaesth. 2023 Aug;131(2):407-417. doi: 10.1016/j.bja.2023.04.041. Epub 2023 Jul 1.

Authors

Alexander J Fowler¹, M A Hussein Wahedally², Tom E F Abbott³, John R Prowle³, David A Cromwell⁴, Rupert M Pearse³

Affiliations

¹ School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal College of Surgeons of England, London, UK. Electronic address: a.fowler@qmul.ac.uk.
² Royal College of Surgeons of England, London, UK.
³ School of Medicine and Dentistry, Queen Mary University of London, London, UK.
⁴ Royal College of Surgeons of England, London, UK; London School of Hygiene and Tropical Medicine, London, UK.

Abstract

Background: The average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described.

Methods: We included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations.

Results: We identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9-4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0-3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs.

Conclusion: One in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.

Keywords: health services research; multi-morbidity; perioperative medicine; surgery; surgical outcomes.

MeSH terms

Adult
Cohort Studies
Elective Surgical Procedures
Humans
Logistic Models
Postoperative Complications* / epidemiology
Retrospective Studies
Risk Factors
Seizures
State Medicine*