Abstract
Purpose
Functional dependency is a known determinant of surgical risk. To enhance our understanding of the relationship between dependency and adverse surgical outcomes, we studied how postoperative mortality following a surgical complication was impacted by preoperative functional dependency.
Methods
We explored a historical cohort of 6,483,387 surgical patients within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). All patients ≥ 18 years old within the ACS-NSQIP from 2007 to 2017 were included.
Results
There were 6,222,611 (96.5%) functionally independent, 176,308 (2.7%) partially dependent, and 47,428 (0.7%) totally dependent patients. Within 30 days postoperatively, 57,652 (0.9%) independent, 15,075 (8.6%) partially dependent, and 10,168 (21.4%) totally dependent patients died. After adjusting for confounders, increasing functional dependency was associated with increased odds of mortality (Partially Dependent OR: 1.72, 99% CI: 1.66 to 1.77; Totally Dependent OR: 2.26, 99% CI: 2.15 to 2.37). Dependency also significantly impacted mortality following a complication; however, independent patients usually experienced much stronger increases in the odds of mortality. There were six complications not associated with increased odds of mortality. Model diagnostics show our model was able to distinguish between patients who did and did not suffer 30-day postoperative mortality nearly 96.7% of the time.
Conclusions
Within our cohort, dependent surgical patients had higher rates of comorbidities, complications, and odds of 30-day mortality. Preoperative functional status significantly impacted the level of postoperative mortality following a complication, but independent patients were most affected.
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Appendices
Appendix 1: Patient Demographics
Summary Statistics | ||||||
|---|---|---|---|---|---|---|
Whole dataset | Totally Independent | Partially Dependent | Totally Dependent | |||
Total Number of Patients | 6,483,387 | 6,222,611 | 176,308 | 47,428 | ||
Death (%) | 84,170 (1.3) | 57,652 (0.9) | 15,075 (8.6) | 10,168 (21.4) | ||
Demographics | Year (%) | 2007 | 210,405 (3.2) | 195,729 (3.1) | 10,236 (5.8) | 4440 (9.4) |
2008 | 269,847 (4.2) | 251,709 (4.0) | 12,963 (7.4) | 5175 (10.9) | ||
2009 | 336,185 (5.2) | 313,595 (5.0) | 16,503 (9.4) | 6087 (12.8) | ||
2010 | 363,431 (5.6) | 343,089 (5.5) | 14,923 (8.5) | 5210 (11.0) | ||
2011 | 442,149 (6.8) | 420,960 (6.8) | 14,120 (8.0) | 3878 (8.2) | ||
2012 | 543,885 (8.4) | 525,316 (8.4) | 13,542 (7.7) | 2903 (6.1) | ||
2013 | 651,940 (10.1) | 628,574 (10.1) | 14,715 (8.3) | 3145 (6.6) | ||
2014 | 750,937 (11.6) | 726,360 (11.7) | 16,006 (9.1) | 3184 (6.7) | ||
2015 | 885,502 (13.7) | 855,685 (13.8) | 20,042 (11.4) | 4178 (8.8) | ||
2016 | 1,000,393 (15.4) | 966,924 (15.5) | 21,245 (12.0) | 4549 (9.6) | ||
2017 | 1,028,713 (15.9) | 994,670 (16.0) | 22,013 (12.5) | 4679 (9.9) | ||
Race (%) | White | 4,747,446 (73.4) | 4,561,675 (73.5) | 126,902 (72.2) | 32,109 (68.0) | |
Black | 643,386 (9.9) | 608,546 (9.8) | 23,364 (13.3) | 8426 (17.9) | ||
Asian | 172,860 (2.7) | 166,434 (2.7) | 3801 (2.2) | 1015 (2.2) | ||
Other | 903,309 (14.0) | 870,373 (14.0) | 21,695 (12.3) | 5644 (12.0) | ||
Sex = Female (%) | 3,691,976 (57.0) | 3,549,090 (57.1) | 98,076 (55.7) | 24,242 (51.2) | ||
Age (years)—median (IQR) | 58 [45, 69] | 57 [44, 68] | 72 [60, 82] | 69 [56, 80] | ||
Height (cm)—median (IQR) | 168 [160, 175] | 168 [160, 175] | 165 [157, 175] | 168 [157, 175] | ||
Weight (kg)—median (IQR) | 81.6 [68.0, 97.5] | 81.6 [68.0, 97.5] | 74.4 [61.2, 90.7] | 72.6 [59.0, 88.9] | ||
Preoperative Comorbidities and Procedural Variables | Surgical Specialty (%) | General Surgery | 3,325,982 (51.3) | 3,211,754 (51.6) | 71,363 (40.5) | 26,090 (55.0) |
Vascular | 484,793 (7.5) | 437,155 (7.0) | 36,437 (20.7) | 8857 (18.7) | ||
Orthopedics | 1,189,299 (18.3) | 1,129,604 (18.2) | 44,290 (25.1) | 6708 (14.1) | ||
Urology | 321,597 (5.0) | 312,158 (5.0) | 5857 (3.3) | 1365 (2.9) | ||
Neurosurgery | 286,015 (4.4) | 273,362 (4.4) | 9168 (5.2) | 1799 (3.8) | ||
Other | 875,700 (13.5) | 858,577 (13.8) | 9193 (5.2) | 2609 (5.5) | ||
Wound Classification (%) | 1 – Clean | 3,575,426 (55.1) | 3,439,672 (55.3) | 96,463 (54.7) | 17,940 (37.8) | |
2 – Clean/ Contaminated | 2,140,662 (33.0) | 2,081,106 (33.4) | 38,687 (21.9) | 10,981 (23.2) | ||
3 – Contaminated | 423,012 (6.5) | 399,617 (6.4) | 14,776 (8.4) | 5693 (12.0) | ||
4 – Dirty/Infected | 344,282 (5.3) | 302,214 (4.9) | 26,382 (15.0) | 12,814 (27.0) | ||
ASA Class (%) | 1 | 583,875 (9.0) | 579,093 (9.3) | 1235 (0.7) | 87 (0.2) | |
2 | 2,912,622 (45.1) | 2,876,798 (46.4) | 18,893 (10.7) | 1886 (4.0) | ||
3 | 2,556,923 (39.6) | 2,417,971 (39.0) | 104,291 (59.3) | 20,239 (42.8) | ||
4/5 | 410,794 (6.4) | 330,433 (5.3) | 51,355 (29.2) | 25,078 (53.0) | ||
Diabetes (%) | 0 – No | 5,486,362 (84.6) | 5,302,856 (85.2) | 120,327 (68.2) | 32,787 (69.1) | |
1 – Insulin | 377,319 (5.8) | 330,895 (5.3) | 33,704 (19.1) | 9797 (20.7) | ||
2 – Non-Insulin | 619,698 (9.6) | 588,860 (9.5) | 22,277 (12.6) | 4844 (10.2) | ||
Dyspnea (%) | 0 – No | 6,044,616 (93.2) | 5,826,783 (93.6) | 145,917 (82.8) | 37,516 (79.1) | |
1 – At Rest | 42,863 (0.7) | 29,051 (0.5) | 7206 (4.1) | 6149 (13.0) | ||
2 – Moderate Exertion | 395,878 (6.1) | 366,762 (5.9) | 23,182 (13.1) | 3761 (7.9) | ||
Sepsis (%) | 0 – None | 6,084,721 (94.0) | 5,884,964 (94.8) | 140,007 (79.6) | 26,515 (56.0) | |
1 – Systemic Inflammatory Response Syndrome (SIRS) | 219,814 (3.4) | 192,436 (3.1) | 18,442 (10.5) | 6972 (14.7) | ||
2 – Sepsis | 135,212 (2.1) | 114,743 (1.8) | 13,177 (7.5) | 6082 (12.8) | ||
3 – Septic Shock | 31,359 (0.5) | 18,641 (0.3) | 4320 (2.5) | 7790 (16.4) | ||
Functional Status (%) | 0 – Totally Independent | 6,222,611 (96.5) | 6,222,611 (100.0) | 0 (0.0) | 0 (0.0) | |
1 – Partially Dependent | 176,308 (2.7) | 0 (0.0) | 176,308 (100.0) | 0 (0.0) | ||
2 – Totally Dependent | 47,428 (0.7) | 0 (0.0) | 0 (0.0) | 47,428 (100.0) | ||
Outpatient (%) | 2,550,335 (39.3) | 2,511,457 (40.4) | 17,433 (9.9) | 2786 (5.9) | ||
Transfer Status = Admitted from other (%) | 274,086 (4.2) | 202,184 (3.3) | 47,389 (26.9) | 21,499 (45.4) | ||
Emergency (%) | 636,169 (9.8) | 575,060 (9.2) | 37,692 (21.4) | 18,058 (38.1) | ||
Smoker (%) | 1,189,267 (18.3) | 1,142,322 (18.4) | 32,105 (18.2) | 7512 (15.8) | ||
Ventilator Dependent (%) | 29,861 (0.5) | 15,185 (0.2) | 2453 (1.4) | 11,582 (24.4) | ||
History of Severe Chronic Obstructive Pulmonary Disease (%) | 296,716 (4.6) | 263,668 (4.2) | 24,312 (13.8) | 6339 (13.4) | ||
Ascites (%) | 30,524 (0.5) | 24,623 (0.4) | 3268 (1.9) | 2401 (5.1) | ||
History of Congestive Heart Failure (%) | 56,817 (0.9) | 41,922 (0.7) | 10,120 (5.7) | 4161 (8.8) | ||
Hypertension Requiring Medication (%) | 2,943,652 (45.4) | 2,771,762 (44.5) | 123,744 (70.2) | 30,723 (64.8) | ||
Acute Renal Failure (%) | 25,937 (0.4) | 19,058 (0.3) | 3786 (2.1) | 2738 (5.8) | ||
Dialysis (%) | 94,879 (1.5) | 75,327 (1.2) | 13,473 (7.6) | 5052 (10.7) | ||
Disseminated Cancer (%) | 142,302 (2.2) | 132,313 (2.1) | 7499 (4.3) | 1738 (3.7) | ||
Open Wound/Wound Infection (%) | 216,208 (3.3) | 157,509 (2.5) | 39,712 (22.5) | 16,980 (35.8) | ||
Steroid Use for Chronic Condition (%) | 226,678 (3.5) | 207,868 (3.3) | 13,610 (7.7) | 3680 (7.8) | ||
Weight Loss (%) | 92,197 (1.4) | 80,291 (1.3) | 8687 (4.9) | 2723 (5.7) | ||
Bleeding Disorder (%) | 294,254 (4.5) | 250,997 (4.0) | 30,855 (17.5) | 9800 (20.7) | ||
Transfusion (%) | 58,983 (0.9) | 45,321 (0.7) | 8075 (4.6) | 4904 (10.3) | ||
Intraoperative/ Postoperative Complications | Return to Operating Room = Yes (%) | 214,429 (3.3) | 189,899 (3.1) | 16,015 (9.1) | 7192 (15.2) | |
Superficial Incisional Surgical Site Infection (%) | 114,112 (1.8) | 106,398 (1.7) | 5692 (3.2) | 1397 (2.9) | ||
Deep Incisional Surgical Site Infection (%) | 36,876 (0.6) | 33,148 (0.5) | 2670 (1.5) | 834 (1.8) | ||
Organ Space Surgical Site Infection (%) | 81,794 (1.3) | 76,040 (1.2) | 3792 (2.2) | 1507 (3.2) | ||
Wound Disruption (%) | 27,445 (0.4) | 24,442 (0.4) | 2058 (1.2) | 785 (1.7) | ||
Pneumonia (%) | 82,053 (1.3) | 66,004 (1.1) | 9817 (5.6) | 5376 (11.3) | ||
Unplanned Intubation (%) | 58,243 (0.9) | 47,258 (0.8) | 6996 (4.0) | 3437 (7.2) | ||
Pulmonary Embolism (%) | 21,471 (0.3) | 19,776 (0.3) | 1172 (0.7) | 418 (0.9) | ||
Progressive Renal Insufficiency (%) | 17,862 (0.3) | 15,411 (0.2) | 1618 (0.9) | 690 (1.5) | ||
Acute Renal Failure (%) | 20,581 (0.3) | 16,516 (0.3) | 2226 (1.3) | 1621 (3.4) | ||
Urinary Tract Infection (%) | 90,406 (1.4) | 78,808 (1.3) | 7861 (4.5) | 3135 (6.6) | ||
Stroke/Cerebrovascular Accident (%) | 13,548 (0.2) | 11,419 (0.2) | 1454 (0.8) | 576 (1.2) | ||
Cardiac Arrest (%) | 21,281 (0.3) | 16,569 (0.3) | 2743 (1.6) | 1703 (3.6) | ||
Myocardial Infarction (%) | 23,347 (0.4) | 19,872 (0.3) | 2545 (1.4) | 705 (1.5) | ||
Transfusions (%) | 329,261 (5.1) | 288,116 (4.6) | 29,329 (16.6) | 9115 (19.2) | ||
Deep Vein Thrombosis Requiring Therapy (%) | 38,829 (0.6) | 34,039 (0.5) | 3085 (1.7) | 1433 (3.0) | ||
Sepsis (%) | 107,620 (1.7) | 93,228 (1.5) | 9392 (5.3) | 4127 (8.7) | ||
Septic Shock (%) | 54,799 (0.8) | 42,644 (0.7) | 7368 (4.2) | 3980 (8.4) | ||
Lab Values | Blood Urea Nitrogen (mg/dL)—median (IQR) | 15.0 [11.0, 19.0] | 15.00 [11.0, 19.0] | 18.5 [13.0, 27.0] | 21.0 [13.0, 33.6] | |
Serum Albumin (g/dL)—median (IQR) | 4.0 [3.6, 4.3] | 4.0 [3.6, 4.3] | 3.3 [2.7, 3.8] | 2.8 [2.2, 3.4] | ||
Total Bilirubin (mg/dL)—median (IQR) | 0.5 [0.4, 0.8] | 0.5 [0.4, 0.8] | 0.5 [0.36, 0.8] | 0.6 [0.4, 0.9] | ||
Serum Glutamic Oxaloacetic Transaminase (units/L)—median (IQR) | 22 [17,29] | 22 [17,29] | 22 [17,31] | 25 [18,41] | ||
Alkaline Phosphatase (units/L)—median (IQR) | 77 [62, 97] | 76 [61, 96] | 87 [68, 118] | 90 [68, 127] | ||
White Blood Cell Count (K/uL)—median (IQR) | 7.40 [5.90, 9.40] | 7.30 [5.90, 9.30] | 8.50 [6.51, 11.40] | 10.0 [7.30, 14.14] | ||
Hematocrit (volume %)—median (IQR) | 40.0 [36.5, 42.9] | 40.0 [36.8, 43.0] | 35.0 [30.5, 39.2] | 32.3 [28.2, 37.1] | ||
Platelet Count (K/uL)—median (IQR) | 241 [198, 291] | 241 [198, 290] | 236 [182, 306] | 234 [167, 319] | ||
International Normalized Ratio of Prothrombin Time values—median (IQR) | 1.0 [1.0, 1.1] | 1.0 [1.0, 1.1] | 1.1 [1.0, 1.2] | 1.2 [1.1, 1.4] | ||
Appendix 2: Missingness Rates
Count | Proportion | |
|---|---|---|
Age | 24,622 | 0.38% |
Sex | 4014 | 0.06% |
Race | 16,386 | 0.25% |
Height | 130,609 | 2.01% |
Weight | 69,082 | 1.07% |
Work Relative Value Unit | 5742 | 0.09% |
In/outpatient | 4 | < 0.00% |
Transfer Status | 5711 | 0.09% |
Anesthesia | 1545 | 0.02% |
Surgical Service | 1 | < 0.00% |
Emergency | 32 | < 0.00% |
Wound Classification | 5 | < 0.00% |
ASA Classification | 19,173 | 0.30% |
Diabetes | 8 | < 0.00% |
Smoke | 25 | < 0.00% |
Dyspnea | 30 | < 0.00% |
Functional Status | 37,040 | 0.57% |
Ventilator | 11 | < 0.00% |
History of Chronic Obstructive Pulmonary Disease | 13 | < 0.00% |
Ascites | 20 | < 0.00% |
History of Congestive Heart Failure | 13 | < 0.00% |
Hypertension | 16 | < 0.00% |
Preoperative Acute Renal Failure | 19 | < 0.00% |
Dialysis | 24 | < 0.00% |
Disseminated Cancer | 17 | < 0.00% |
Open Wound/Wound Infection | 17 | < 0.00% |
Steroid | 17 | < 0.00% |
Weight Loss | 18 | < 0.00% |
Bleeding Disorder | 15 | < 0.00% |
Preop Transfusion | 20 | < 0.00% |
Systemic Sepsis | 12,281 | 0.19% |
Operation Time | 945 | 0.01% |
Hospital Length of Stay | 5683 | 0.09% |
Days from Admission to Surgery | 239 | < 0.00% |
Return to Operating Room | 55 | < 0.00% |
Serum Sodium | 1,232,739 | 19.01% |
Blood Urea Nitrogen | 1,416,070 | 21.84% |
Serum Creatinine | 1,186,261 | 18.30% |
Serum Albumin | 3,150,009 | 48.59% |
Total Bilirubin | 3,151,874 | 48.61% |
Serum Glutamic Oxaloacetic Transaminase | 3,145,901 | 48.52% |
Alkaline Phosphatase | 3,131,423 | 48.30% |
White Blood Cell Count | 1,033,486 | 15.94% |
Hematocrit | 942,893 | 14.54% |
Platelet Count | 1,037,770 | 16.01% |
Partial Thromboplastin Time | 4,278,329 | 65.99% |
International Normalized Ratio (INR) of Prothrombin Time values | 3,732,736 | 57.57% |
Prothrombin Time | 5,809,086 | 89.60% |
Appendix 3: Totally Dependent Patients with Unplanned Intubation Cohort Summary
Lived | Died | ||
|---|---|---|---|
Count (%) | 2112 (5.4) | 1326 (7.2) | |
Sex = Female (%) | 945 (44.8) | 618 (46.6) | |
Age (years)—median (IQR) | 65 [54, 75] | 72 [61, 81] | |
Weight (kg)—median (IQR) | 76 [63, 94] | 71 [59, 87] | |
Wound Classification (%) | 1 – Clean | 560 (26.5) | 372 (28.1) |
2 – Clean/ Contaminated | 510 (24.1) | 299 (22.5) | |
3 – Contaminated | 328 (15.5) | 210 (15.8) | |
4 – Dirty/Infected | 714 (33.8) | 445 (33.6) | |
ASA Class (%) | 1 | 1 (0.0) | 1 (0.1) |
2 | 38 (1.8) | 13 (1.0) | |
3 | 677 (32.1) | 379 (28.6) | |
4/5 | 1391 (66.0) | 933 (70.4) | |
Diabetes (%) | 0 – No | 1492 (70.6) | 896 (67.6) |
1 – Insulin | 398 (18.8) | 286 (21.6) | |
2 – Non-Insulin | 222 (10.5) | 144 (10.9) | |
Dyspnea (%) | 0 – No | 1420 (67.2) | 872 (65.8) |
1 – At Rest | 462 (21.9) | 297 (22.4) | |
2 – Moderate Exertion | 230 (10.9) | 157 (11.8) | |
Sepsis (%) | 0 – None | 750 (35.5) | 478 (36.1) |
1 – Systemic Inflammatory Response Syndrome (SIRS) | 403 (19.1) | 270 (20.4) | |
2 – Sepsis | 312 (14.8) | 269 (20.3) | |
3 – Septic Shock | 646 (30.6) | 307 (23.2) | |
Outpatient (%) | 14 (0.7) | 14 (1.1) | |
Transfer Status = Admitted from other (%) | 927 (43.9) | 624 (47.1) | |
Emergency (%) | 1144 (54.2) | 662 (49.9) | |
Smoker (%) | 474 (22.4) | 250 (18.9) | |
Ventilator Dependent (%) | 863 (40.9) | 352 (26.5) | |
History of Severe Chronic Obstructive Pulmonary Disease (%) | 373 (17.7) | 251 (18.9) | |
Ascites (%) | 174 (8.2) | 138 (10.4) | |
History of Congestive Heart Failure (%) | 282 (13.4) | 205 (15.5) | |
Hypertension Requiring Medication (%) | 1384 (65.5) | 936 (70.6) | |
Acute Renal Failure (%) | 182 (8.6) | 109 (8.2) | |
Dialysis (%) | 225 (10.7) | 241 (18.2) | |
Disseminated Cancer (%) | 62 (2.9) | 85 (6.4) | |
Open Wound/Wound Infection (%) | 678 (32.1) | 526 (39.7) | |
Steroid Use for Chronic Condition (%) | 200 (9.5) | 176 (13.3) | |
Weight Loss (%) | 141 (6.7) | 136 (10.3) | |
Bleeding Disorder (%) | 497 (23.5) | 352 (26.5) | |
Transfusion (%) | 268 (12.7) | 180 (13.6) | |
Return to Operating Room = Yes (%) | 743 (35.2) | 315 (23.8) | |
Superficial Incisional Surgical Site Infection (%) | 112 (5.3) | 33 (2.5) | |
Deep Incisional Surgical Site Infection (%) | 70 (3.3) | 33 (2.5) | |
Organ Space Surgical Site Infection (%) | 168 (8.0) | 76 (5.7) | |
Wound Disruption (%) | 95 (4.5) | 53 (4.0) | |
Pneumonia (%) | 959 (45.4) | 494 (37.3) | |
Unplanned Intubation (%) | 2112 (100.0) | 1326 (100.0) | |
Pulmonary Embolism (%) | 59 (2.8) | 30 (2.3) | |
Progressive Renal Insufficiency (%) | 85 (4.0) | 53 (4.0) | |
Acute Renal Failure (%) | 168 (8.0) | 137 (10.3) | |
Urinary Tract Infection (%) | 264 (12.5) | 115 (8.7) | |
Stroke/Cerebrovascular Accident (%) | 62 (2.9) | 49 (3.7) | |
Cardiac Arrest (%) | 174 (8.2) | 472 (35.6) | |
Myocardial Infarction (%) | 71 (3.4) | 87 (6.6) | |
Transfusions (%) | 472 (22.3) | 349 (26.3) | |
Deep Vein Thrombosis Requiring Therapy (%) | 186 (8.8) | 69 (5.2) | |
Sepsis (%) | 393 (18.6) | 156 (11.8) | |
Septic Shock (%) | 614 (29.1) | 527 (39.7) | |
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Clifton, J.C., Engoren, M., Shotwell, M.S. et al. The Impact of Functional Dependence and Related Surgical Complications on Postoperative Mortality. J Med Syst 46, 6 (2022). https://doi.org/10.1007/s10916-021-01779-8
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DOI: https://doi.org/10.1007/s10916-021-01779-8