Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities

Rosen, Claire; Wirtalla, Chris; Keele, Luke; Roberts, Sanford E.; Kaufman, Elinore J.; Holena, Daniel N.; Halpern, Scott D.; Kelz, Rachel R.

doi:10.1097/mlr.0000000000001733

Cited by 9 publications

(11 citation statements)

References 37 publications

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“…Understanding, and highlighting, the variation found in this analysis is important, as EGS is a heterogenous field, and as such, generalizations about EGS as a unit lack the granular details necessary to provide evidence-based personalized medicine to future patients. Our prior work, 20 and that of Ho et al, 39 have found a higher risk of adverse outcomes for those after EGS to be associated with multimorbidity and poor functional status. Though we did find that multimorbidity significantly increased the risk associated with operative management with regards to in-hospital mortality for patients with general abdominal and upper GI conditions, along with 30-day mortality and nonroutine discharge for patients with upper GI conditions, for patients with HPB conditions, operative management was associated with lower risk of adverse outcomes than nonoperative management, regardless of multimorbidity status.…”

Section: Discussionmentioning

confidence: 70%

“…When patients have many medical problems, these comorbidities have the potential to interact, influencing a patient’s overall health, and adding complexity to studying this patient population, which limits evidence-based clinical decision support for such patients 27–29 . QCSs, developed by Silber et al, 25 consider these interactions and have been shown to outperform other measures of multimorbidity 20,25,26 …”

Section: Methodsmentioning

confidence: 99%

“…[27][28][29] QCSs, developed by Silber et al, 25 consider these interactions and have been shown to outperform other measures of multimorbidity. 20,25,26…”

Section: Exposuresmentioning

confidence: 99%

“…As such, multimorbidity has been recognized as a global health challenge and is a focus of ongoing research by the National Institutes of Health 17–19 . Our prior research demonstrates that older multimorbid patients undergoing operative treatment for EGS conditions have a 2-fold increased risk of in-hospital mortality when compared with similar patients without interacting comorbid conditions 20 . To date, limited contemporary data exists regarding the impact of multimorbidity on outcomes for EGS patients managed nonoperatively, which is greater than two-thirds of patients with EGS conditions 1,8 .…”

mentioning

confidence: 99%

“…[17][18][19] Our prior research demonstrates that older multimorbid patients undergoing operative treatment for EGS conditions have a 2-fold increased risk of in-hospital mortality when compared with similar patients without interacting comorbid conditions. 20 To date, limited contemporary data exists regarding the impact of multimorbidity on outcomes for EGS patients managed nonoperatively, which is greater than two-thirds of patients with EGS conditions. 1,8 Furthermore, given the inherent selection bias associated with whether a patient is managed operatively or nonoperatively, traditional observational study designs limit direct comparison between these two treatment groups.…”

mentioning

confidence: 99%

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The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions

et al. 2023

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Objective: To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions. Background: EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity. Methods: Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions. Results: Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: −11.5%, P < 0.001; nonmultimorbid: −11.9%, P < 0.001) and 30-day readmissions (multimorbid: −8.2%, P = 0.002; nonmultimorbid: −9.7%, P < 0.001) among hepatobiliary patients. Conclusions: The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.

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Section: Discussionmentioning

confidence: 70%

Section: Methodsmentioning

confidence: 99%

“…[27][28][29] QCSs, developed by Silber et al, 25 consider these interactions and have been shown to outperform other measures of multimorbidity. 20,25,26…”

Section: Exposuresmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions

et al. 2023

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Practice patterns and clinical outcomes in acute appendicitis differ in the elderly patient

Cimino,

Biloslavo,

Kurihara

et al. 2024

Eur J Trauma Emerg Surg

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Background Appendicitis is the most frequent global abdominal surgical emergency. An ageing population, who often exhibit atypical symptoms and delayed presentations, challenge conventional diagnostic and treatment paradigms. Objectives This study aims to delineate disparities in presentation, management, and outcomes between elderly patients and younger adults suffering from acute appendicitis. Methods This subgroup analysis forms part of ESTES SnapAppy, a time-bound multi-center prospective, observational cohort study. It includes patients aged 15 years and above who underwent laparoscopic appendectomy during a defined 90-day observational period across multiple centers. Statistical comparisons were performed using appropriate tests with significance set at p < 0.05. Results The study cohort comprised 521 elderly patients (≥65 years) and 4,092 younger adults (18–64 years). Elderly patients presented later (mean duration of symptoms: 7.88 vs. 3.56 days; p < 0.001) and frequently required computed tomography (CT) scans for diagnosis (86.1% vs. 54.0%; p < 0.001). The incidence of complicated appendicitis was higher in the elderly (46.7% vs. 20.7%; p < 0.001). Delays in surgical intervention were notable in the elderly (85.0% operated within 24 h vs. 88.7%; p = 0.018), with longer operative times (71.1 vs. 60.3 min; p < 0.001). Postoperative complications were significantly higher in the elderly (27.9% vs. 12.9%; p < 0.001), including severe complications (6.9% vs. 2.4%; p < 0.001) and prolonged hospital stays (7.9 vs. 3.6 days; p < 0.001). Conclusions Our findings highlight significant differences in the clinical course and outcomes of acute appendicitis in the elderly compared to younger patients, suggesting a need for age-adapted diagnostic pathways and treatment strategies to improve outcomes in this vulnerable population.

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Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries

Roberts

Rosen

Wirtalla

et al. 2023

The American Journal of Surgery

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Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities

Cited by 9 publications

References 37 publications

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions

Practice patterns and clinical outcomes in acute appendicitis differ in the elderly patient

Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries

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