Primary Care Use and 90-Day Mortality Among Older Adults Undergoing Cancer Surgery.

IF 15.7 1区 医学 Q1 SURGERY JAMA surgery Pub Date : 2024-10-01 DOI:10.1001/jamasurg.2024.2598
Hadiza S Kazaure, N Ben Neely, Lauren E Howard, Terry Hyslop, Mohammad Shahsahebi, Leah L Zullig, Kevin C Oeffinger
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Abstract

Importance: Multimorbidity and postoperative clinical decompensation are common among older surgical patients with cancer, highlighting the importance of primary care to optimize survival. Little is known about the association between primary care use and survivorship among older adults (aged ≥65 years) undergoing cancer surgery.

Objective: To examine primary care use among older surgical patients with cancer and its association with mortality.

Design, setting, and participants: In this retrospective cohort study, data were abstracted from the electronic health record of a single health care system for older adults undergoing cancer surgery between January 1, 2017, and December 31, 2019. There were 3 tiers of stratification: (1) patients who had a primary care practitioner (PCP) (physician, nurse practitioner, or physician assistant) vs no PCP, (2) those who had a PCP and underwent surgery in the same health system (unfragmented care) vs not (fragmented care), and (3) those who had a primary care visit within 90 postoperative days vs not. Data were analyzed between August 2023 and January 2024.

Exposure: Primary care use after surgery for colorectal, head and neck, prostate, ovarian, pancreatic, breast, liver, renal cell, non-small cell lung, endometrial, gastric, or esophageal cancer.

Main outcomes and measures: Postoperative 90-day mortality was analyzed using inverse propensity weighted Kaplan-Meier curves, with log-rank tests adjusted for propensity scores.

Results: The study included 2566 older adults (mean [SEM] age, 72.9 [0.1] years; 1321 men [51.5%]). Although 2404 patients (93.7%) had health insurance coverage, 743 (28.9%) had no PCP at the time of surgery. Compared with the PCP group, the no-PCP group had a higher 90-day postoperative mortality rate (2.0% vs 3.6%, respectively; adjusted P = .03). For the 823 patients with unfragmented care, 400 (48.6%) had a primary care visit within 90 postoperative days (median time to visit, 34 days; IQR, 20-57 days). Patients who had a postoperative primary care visit were more likely to be older, have a higher comorbidity burden, have an emergency department visit, and be readmitted. However, they had a significantly lower 90-day postoperative mortality rate than those who did not have a primary care visit (0.3% vs 3.3%, respectively; adjusted P = .001).

Conclusions and relevance: These findings suggest that follow-up with primary care within 90 days after cancer surgery is associated with improved survivorship among older adults.

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接受癌症手术的老年人使用初级保健和 90 天死亡率。
重要性:在老年癌症手术患者中,多病症和术后临床失代偿现象很常见,这凸显了初级保健对优化生存的重要性。人们对接受癌症手术的老年人(年龄≥65 岁)使用初级医疗服务与存活率之间的关系知之甚少:研究老年癌症手术患者使用初级医疗服务的情况及其与死亡率的关系:在这项回顾性队列研究中,从单一医疗保健系统的电子健康记录中抽取了2017年1月1日至2019年12月31日期间接受癌症手术的老年人的数据。共分为三层:(1)有初级保健医生(PCP)(医生、护士或医生助理)的患者与没有初级保健医生的患者;(2)有初级保健医生且在同一医疗系统接受手术的患者(非碎片化护理)与没有初级保健医生的患者(碎片化护理);(3)术后 90 天内接受初级保健访问的患者与没有初级保健访问的患者。数据分析时间为 2023 年 8 月至 2024 年 1 月:暴露:结直肠癌、头颈部癌、前列腺癌、卵巢癌、胰腺癌、乳腺癌、肝癌、肾细胞癌、非小细胞肺癌、子宫内膜癌、胃癌或食管癌术后的初级护理:采用反倾向加权卡普兰-梅耶曲线分析术后90天死亡率,并根据倾向得分进行对数秩检验:研究纳入了 2566 名老年人(平均 [SEM] 年龄 72.9 [0.1]岁;1321 名男性 [51.5%])。虽然有 2404 名患者(93.7%)享有医疗保险,但其中 743 名患者(28.9%)在手术时没有初级保健医生。与初级保健医生组相比,无初级保健医生组的术后 90 天死亡率更高(分别为 2.0% 和 3.6%;调整后 P = 0.03)。在 823 名接受非碎片化护理的患者中,有 400 人(48.6%)在术后 90 天内接受了初级保健就诊(就诊时间中位数为 34 天;IQR 为 20-57 天)。术后接受初级保健就诊的患者更有可能年龄较大、合并症较多、曾在急诊科就诊并再次入院。然而,他们的术后 90 天死亡率却明显低于没有接受初级保健就诊的患者(分别为 0.3% vs 3.3%;调整后 P = .001):这些研究结果表明,在癌症手术后 90 天内进行初级保健随访与改善老年人的存活率有关。
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来源期刊
JAMA surgery
JAMA surgery SURGERY-
CiteScore
20.80
自引率
3.60%
发文量
400
期刊介绍: JAMA Surgery, an international peer-reviewed journal established in 1920, is the official publication of the Association of VA Surgeons, the Pacific Coast Surgical Association, and the Surgical Outcomes Club.It is a proud member of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications.
期刊最新文献
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