Predictors of Postoperative Complications in 10, 623 Patients Undergoing Elective Hand Surgeries: Who Should be Operated On in an Outpatient Setting?
Kalpit N. Shah, MD; Steven F. DeFroda, MD, MEng; Bo Wang, BS; Arnold Peter C. Weiss, MD
Brown University, Providence, RI
A large portion of hand surgeries are performed on an outpatient basis. Lower costs of performing a surgery in a stand-alone outpatient surgery center compared to in-hospital outpatient center or the main in-hospital operating rooms make the choice financially appealing. In current practice, many stand-alone surgery centers use arbitrary patient factors in deciding who has surgical procedures at an outpatient stand-alone surgery. Often cited is the concern of higher risk of perioperative and postoperative complications for patients. However, the association between certain objective patient factors or comorbidities and post-operative complications have not been established.
Patients undergoing elective hand surgeries (152 CPT codes from all hand surgery CPT codes) in an outpatient setting under non-general anesthesia between 2005 and 2015 were idenitified in the National Surgical Quality Improvement Program (NSQIP) database. Inpatients and those who had an unrelated operation in the prior 30 days were excluded to identify a truly elective hand-surgery patient population. The primary outcome was postoperative complications, which included 30-day mortality, surgical or medical complications (UTIs were excluded), incidence of return to the operating room (OR) or readmission for reasons related to their surgery. Patients demographcs, intraoperative and post-operative variables were recorded. Factors significant simple hypothesis testing were then used in a multiple logistic regression.
Of 10,623 patients undergoing elective hand surgeries between 2005 and 2015, 159 (1.5%) developed a total of 207 medical or surgical complications, death, return to the OR or had to be readmitted. In multiple logistic regression analysis, ASA Class (OR 1.78, 95% CI [1.15, 2.74], p=0.0092), steroid use (OR 2.87, 95% CI [1.63, 5.05], p=0.0003), dialysis use (OR 8.22, 95% CI [4.13, 16.37], P<0.0001), bleeding disorder and smoking status were significant for predictors following the outpatient surgery. Stepwise selection was used to search for the best subset of variables that minimize the AIC of the logistic regression model.
The analysis based on the NSQIP database may help identify and exclude who are at risk for significant complications post-operatively and should not be operated on at a stand-alone outpatient surgery centers. These factors included ASA class 4, current steroid use, current dialysis use, bleeding disorder and smoking status. The result of this study can help surgeons choose patients appropriately for the proposed venue of the surgery.
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