Development and validation of predictive model for long-term hospitalization, readmission, and in-hospital death of patients over 60 years old

ABSTRACT Objective To develop and validate a high-risk predictive model that identifies, at least, one common adverse event in older population: early readmission (up to 30 days after discharge), long hospital stays (10 days or more) or in-hospital deaths. Methods This was a retrospective cohort study including patients aged 60 years or older (n=340) admitted at a 630-beds tertiary hospital, located in the city of São Paulo, Brazil. A predictive model of high-risk indication was developed by analyzing logistical regression models. This model prognostic capacity was assessed by measuring accuracy, sensitivity, specificity, and positive and negative predictive values. Areas under the receiver operating characteristic curve with 95% confidence intervals were also obtained to assess the discriminatory power of the model. Internal validation of the prognostic model was performed in a separate sample (n=168). Results Statistically significant predictors were identified, such as current Barthel Index, number of medications in use, presence of diabetes mellitus, difficulty chewing or swallowing, extensive surgery, and dementia. The study observed discrimination model acceptance in the construction sample 0.77 (95% confidence interval: 0.71-0.83) and good calibration. The characteristics of the validation samples were similar, and the receiver operating characteristic curve area was 0.687 (95% confidence interval: 0.598-0.776). We could assess an older patient's adverse health events during hospitalization after admission. Conclusion A predictive model with acceptable discrimination was obtained, with satisfactory results for early readmission (30 days), long hospital stays (10 days), or in-hospital death.

Associação entre funcionalidade e tempo de permanência de pacientes críticos em UTI / Association between functionality and length of stay of critical ICU patients

Introdução: A imobilidade no leito de pacientes em unidades de terapia intensiva (UTI) favorece o maior tempo de permanência na unidade. Objetivos: Comparar a funcionalidade na admissão e na alta da UTI segundo a especialidade médica e correlacionar a funcionalidade na alta com o tempo de internação na UTI. Métodos: Estudo exploratório, longitudinal, realizado na UTI Geral de um hospital escola. Os pacientes foram divididos em grupos de acordo com a especialidade de internação: neurologia, pneumologia, gastroenterologia, politrauma e outros. O estado funcional prévio à internação foi obtido por meio da medida de independência funcional (MIF). Na alta foi aplicada a escala de mobilidade funcional em UTI (EMU). Resultados: Amostra de 174 pacientes, 53% do sexo masculino. O grupo politrauma apresentou idade significativamente menor que os outros grupos (p < 0,0001). O tempo médio de internação para os grupos neurologia e pneumologia apresentou correlação inversamente proporcional com p = 0 ,02 / r = -0,5 e p = 0,009 / r = - 0,4 respectivamente. Não houve diferença significativa entre as médias da MIF na admissão (p = 0,11) e da EMU na alta (p = 0,24) entre as especialidades médicas em que os pacientes foram admitidos. Conclusão: Quanto maior o tempo de internação na UTI, menor a funcionalidade na alta em pacientes neurológicos e pneumopatas. (AU)

Introduction: Patients on bed rest in intensive care units (ICU) prolong length of stay in the unit. Objectives: To compare ICU admission and discharge functionality according to medical specialty, and to correlate ICU discharge functionality with ICU length of stay. Methods: Longitudinal exploratory study, performed at the General ICU of a teaching hospital. The patients were divided into groups according to the hospitalization specialty: neurology, pneumology, gastroenterology, polytrauma and others. The functional status prior to hospitalization was obtained through the functional independence measure (FIM). At discharge, the ICU functional mobility scale (FMS) was applied. Results: A sample of 174 patients, 53% male. The polytrauma group was significantly younger than the other groups (p < 0.0001). The mean length of stay for the neurology and pneumology groups was inversely proportional to p = 0.02 / r = -0.5 and p = 0.009 / r = -0.4, respectively. There was no significant difference between the mean FIM at admission (p = 0.11) and FMS at discharge (p = 0.24) between the medical specialties at which patients were admitted. Conclusion: The longer the patient stays in the IC, the lower functionality at discharge in neurological and lung disease patients. (AU)

Características de los pacientes con estancia prolongada en el servicio de cirugía general del Hospital Nacional Almanzor Aguinaga Asenjo / Features of long term hospital stay patients in general surgery at Hospital Nacional Almanzor Aguinaga Asenjo

Introducción: La estancia hospitalaria prolongada constituye una preocupación a nivel mundial por sus efectos negativos en el sistema de salud, aumentando los costos, generando deficiencia en la accesibilidad de prestación de servicios de salud, saturación de unidades de hospitalización y urgencias y por consiguiente mayores efectos adversos como lo son las enfermedades intrahospitalarias. Objetivo: Determinar las características de los pacientes con estancia hospitalaria prolongada en el servicio de Cirugía General del HNAAA. Resultados: Se encontró una media de 15 días de hospitalización entre los pacientes con estancia prolongada. Las características más encontradas en estos pacientes fueron la demora en la realización del procedimiento quirúrgico, la no relación con un trabajador dentro del sistema de salud (74%), edad mayor a 65 (58%) , ser del sexo femenino (54%) y tener alguna neoplasia del tracto gastrointestinal (cáncer de colon: 16%, ampuloma 10%, cáncer de estómago: 8%). Conclusión: Las características encontradas en los pacientes con estancia hospitalaria prolongada más comunes fueron la demora en la realización del procedimiento quirúrgico, la demora en la respuesta a interconsultas, la no relación a un trabajador asistencial, administrativo o de limpieza en el sistema de salud, edad mayor a 65, ser del sexo femenino y tener alguna neoplasia del tracto gastrointestinal.

Introduction: Prolonged hospitalization constitutes a grave concern worldwide because its negative effects on the health system, raising their costs, generating a health service provision deficit, hospitalization and urgencies department saturation and as a result, greater adverse effects such as intrahospitalary diseases. Objective: Determine the characteristics of patients with prolonged hospital stay in the General Surgery service of the HNAAA. Results: It was found a mean of 15 days of hospitalization in long-stay patients. The characteristics most found in those patients were the delay in surgical procedures, abscense of a health system worker proximity (74%), age older than 65 years (58%) , being female (54%) and having a gastro i n t e s t i n a l n e o p l a s m ( c o l o n c a n c e r : 1 6 % , ampuloma:10%, stomach cancer: 8%). Conclusion: The most common characteristics found were the delay in surgical procedure perform, delay in interconsult answer, the absence of an inside known doctor, administrative worker or cleaning service worker, age beyond 65 years, being female and having a gastro intestinal tract cancer.

Does cha2ds2-vasc score predict mace in patients undergoing isolated coronary artery bypass grafting surgery?

Abstract Objective: To evaluate the prognostic value of CHA2DS2-VASc score in individuals undergoing isolated coronary artery bypass grafting (CABG) surgery. Methods: Records of consecutive 464 patients who underwent elective isolated CABG, between January 2015 and August 2017, were retrospectively reviewed. A major adverse cardiac event (MACE) was the primary outcome of this study. MACE in patients with low (L) (<2, n: 238) and high (H) (≤2, n: 226) CHA2DS2-VASc scores were compared. Univariate logistic regression analysis identified preditors of MACE. Results: Hypertension, diabetes mellitus, and peripheral vascular disease were more frequent in the H group than in the L group. European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and SYNTAX I scores were similar in both groups while SYNTAX II-CABG score was significantly higher in the H group than in the L group. Postoperative myocardial infarction, need for intra-aortic balloon pump, acute renal failure, and mediastinitis were more frequent in the H group than in the L group. The H group had significantly higher in-hospital mortality and MACE rates than the L group (P<0.01). EuroSCORE I, SYNTAX II-CABG, and CHA2DS2-VASc scores were predictors for MACE. SYNTAX II-CABG > 25.1 had 68.4% sensitivity and 52.7% specificity (area under the curve [AUC]: 0.653, P=0.04, 95% confidence interval [CI]: 0.607-0.696) and CHA2DS2-VASc > 2 had 52.6% sensitivity and 84.1% specificity (AUC: 0.752, P<0.01, 95% CI: 0.710-0.790) to predict MACE. Pairwise comparison of receiver-operating characteristic curves revealed similar accuracy for both scoring systems. Conclusion: CHA2DS2-VASc score may predict MACE in patients undergoing isolated CABG.

Impacto do estado nutricional e do tempo de jejum nas complicações gastrointestinais e no tempo de hospitalização em pacientes cirúrgicos / Impact of the nutritional status and fasting time in gastrointestinal complications and hospitalization time in surgical patients

Introdução: O estado nutricional e o tempo de jejum pré e pós-cirúrgico impactam na morbimortalidade de pacientes submetidos a cirurgias eletivas. No Brasil, o tempo de jejum prolongado e a elevada prevalência de desnutrição são comuns nos hospitais terciários. Objetivo: Realizar levantamento do tempo de jejum médio praticado em hospital terciário e avaliar o impacto do jejum pré e pós-cirúrgico e do estado nutricional nas complicações gastrointestinais imediatas e no tempo de hospitalização em pacientes cirúrgicos. Material e métodos: Estudo prospectivo, realizado no Hospital Universitário Walter Cantídio, em Fortaleza. Foram avaliados 173 indivíduos submetidos a cirurgias eletivas de médio e grande porte entre agosto de 2016 a janeiro de 2017. Foram coletadas medidas antropométricas, hemograma e informações como tempo de jejum pré e pós-cirúrgico, permanência hospitalar e complicações gastrointestinais. As análises de correlação e associação foram realizadas no Software SPSS®, com nível de significância fixado em p< 0,05. Resultados: A maioria dos pacientes (71,1%) foi submetida à cirurgia de porte II (grande porte). Houve correlação negativa entre tempo de permanência hospitalar e índice de massa corporal [r= -0,223; p= 0,003], circunferência braquial [r= -0,335; p< 0,001], dobra cutânea tricipital [r= -0,320; p< 0,001], área muscular do braço corrigida [r= -0,253; p= 0,001], contagem total de linfócitos [r= -0,223; p= 0,008], hemoglobina [r= -0,243; p= 0,004] e relação linfócito/monócito [r= -0,308; p< 0,001]. Adicionalmente, houve correlação positiva entre tempo de permanência hospitalar com o tempo de jejum pós-cirúrgico [r= 0,456; p< 0,001]. Ausência de complicações gastrointestinais foi associada a valores de triagem (Nutritional Risk Screenin-2002) < 3 (p= 0,034) e entre menor tempo de jejum pós-cirúrgico (p= 0,033). Conclusão: Pacientes desnutridos, com maior risco nutricional e os que se submeteram a um tempo de jejum pós-cirúrgico elevado apresentaram maior tempo de permanência hospitalar e maior incidência de complicações gastrointestinais.

Introduction: The nutritional status and pre and postoperative fasting time impact the morbidity and mortality of patients undergo to elective surgeries. In Brazil, prolonged fasting time and high prevalence of malnutrition are common in tertiary hospitals. Objective: To evaluate the mean preoperative and postoperative fasting time and the impact of fasting, and nutritional status on gastrointestinal complications and on length of hospital stay in surgical patients. Material and methods: A prospective study, conducted at Walter Cantídio University Hospital, in Fortaleza. One hundred and seventy three surgery patients were evaluated between August 2016 and January 2017. The subjects were divided in two groups (medium and large size). Anthropometric measurements, blood count and information about pre and postoperative fasting time, hospital stay and gastrointestinal complications data were collected. Correlation and association test were performed by Software SPSS®. P<0.05 was considered significant. Results: The majority of the patients (71,1%) were included in size II (large) surgery. There was a negative correlation between length of stay in hospital and body mass index [r= -0,223; p= 0,003], brachial circumference [r= -0,335; p<0,001], triceps skinfold thickness [r= -0,320; p<0,001], arm muscle area [r= -0,253; p= 0,001], total lymphocyte count [r= -0,223; p= 0,008], hemoglobin [r= -0,243; p= 0,004] and lymphocyte/monocyte ratio [r= -0,308; p<0,001]. In addition, there was a positive correlation between length of stay in hospital and postoperative fasting time [r= 0,456; p<0,001]. Absence of gastrointestinal complications was associated with Nutrition Risk Screening-2002 <3 (p= 0,034) and shorter post-operative fasting time (p= 0,033). Conclusion: Malnourished patients, higher nutritional risk and higher postoperative fasting time were associated to longer hospital stay and a higher incidence of gastrointestinal complications.

Impacto da disfunção renal na evolução intra-hospitalar após cirurgia de revascularização miocárdica / Impact of renal failure on in-hospital outcomes after coronary artery bypass surgery

FUNDAMENTO: A doença renal crônica (DRC) é um marcador de mortalidade na cirurgia de revascularização miocárdica (CRM). OBJETIVO: Avaliar em pacientes com DRC submetidos a CRM as características clínicas e os marcadores de morbimortalidade hospitalar; comparar a evolução intra-hospitalar entre os grupos com e sem DRC, e com e sem desenvolvimento de insuficiência renal aguda (IRA). MÉTODOS: Foram analisadas as CRM isoladas realizadas num hospital público cardiológico de 1999 a 2007. Considerado disfunção renal quando creatinina > 1,5 mg/dl. Avaliaram-se características clínicas, mortalidade e complicações pós-operatórias conforme a função renal. RESULTADOS: De 3.890 pacientes, 362 (9,3 por cento) tinham DRC. Esse grupo apresentava idade mais avançada, maior prevalência de hipertensão, disfunção ventricular esquerda, acidente vascular encefálico (AVE) prévio, doença arterial periférica e triarteriais. No pós-operatório, apresentou maior incidência de AVE (5,5 por cento vs 2,1 por cento), fibrilação atrial (16 vs 8,3 por cento), síndrome de baixo débito cardíaco (14,4 por cento vs 8,5 por cento), maior tempo de internação na unidade de terapia intensiva (4,04 vs 2,83 dias), e maior mortalidade intra-hospitalar (10,5 por cento vs 3,8 por cento). Sexo feminino, tabagismo, diabete e doença vascular periférica e/ou carotídea associaram-se com maior mortalidade no grupo DRC. Pacientes que não desenvolveram IRA pós-operatória apresentaram 3,5 por cento de mortalidade; grupo IRA não dialítica: 35,4 por cento; grupo IRA dialítica: 66,7 por cento. Calculando-se a taxa de filtração glomerular, observou-se aumento da mortalidade conforme o aumento da classe da DRC. CONCLUSÃO: Pacientes com DRC submetidos a CRM constituem população de elevado risco, apresentando maior morbimortalidade. IRA pós-operatória é importante marcador de mortalidade. A taxa de filtração glomerular foi inversamente relacionada com mortalidade.

BACKGROUND: Chronic kidney disease (CKD) is a predictor of increased mortality in patients undergoing coronary artery bypass surgery (CABG). OBJECTIVE: To evaluate the characteristics and predictors of increased mortality in the CKD population submitted to CABG. To compare in-hospital outcomes between patients with and without CKD, and with and without development of acute renal failure (ARF). METHODS: Retrospective analysis of a prospective database of all isolated CABG performed in a single public tertiary hospital from 1999 to 2007. CKD was considered when creatinine > 1.5 mg/dl. Clinical characteristics, mortality and post-operative complications were evaluated according to renal function. RESULTS: Of 3,890 patients, 362 (9.3 percent) had CKD. This population was older, presented grater prevalence of hypertension, left ventricular dysfunction, previous stroke, peripheral vascular disease and three-vessel disease. In-hospital outcomes revealed greater incidence of stroke (5.5 percent vs 2.1 percent), atrial fibrillation (16 vs 8.3 percent), low cardiac ouput syndrome (14.4 percent vs 8.5 percent), longer stay in intensive care unit (4.04 vs 2.83 days), and greater mortality (10.5 percent vs 3.8 percent). Logistic regression: female gender, smoking, diabetes and peripheral vascular disease were associated with higher in-hospital mortality within the CKD group. Patients who did not develop post-operative ARF presented 3.5 percent mortality; non-dialytic ARF: 35.4 percent; dialytic ARF: 66.7 percent mortality. Mortality was directly related to the stage of CKD, according to glomerular filtration rate. CONCLUSION: CKD patients submitted to CABG represent a high risk population, with increased incidence of complications and mortality. Post-operative ARF is a strong in-hospital mortality predictor. Glomerular filtration rate was inversely related to mortality.

Risco nutricional em cirurgia avaliado pelo índice de massa corporal ajustado ou não para pacientes idosos / Nutritional risk in surgery evaluated by body mass index adjusted or not to elderly patients / Nutritional risk in surgery evaluated by body mass index adjusted or not to elderly patients

RACIONAL: O índice de massa corporal vem sendo usado indistintamente entre idosos ou não para a avaliação do estado nutricional. A hipótese deste trabalho é a de que em pacientes idosos um ponto de corte mais alto para o índice de massa corporal pode ter maior validade na aferição do risco nutricional em cirurgia. OBJETIVO: Avaliar a morbimortalidade em pacientes cirúrgicos idosos comparada a pacientes mais jovens e sua associação com valores baixos de índice de massa corporal utilizando-se um ponto de corte convencional (18,5 kg/m²) e outro adaptado para pacientes com idade avançada (24 kg/m²). PACIENTES E MÉTODOS: Um mil e novecentos e doze pacientes foram divididos em dois grupos: <65 anos n = 1627) e >65 anos (n = 285). Comparou-se nos dois grupos o tempo de internação e a morbimortalidade. Pacientes com idade >65 anos foram estratificados segundo o índice de massa corporal <18,5 kg/m² ou <24 kg/m², e analisados quanto a complicações pós-operatórias, reoperações, óbito e tempo de internação. RESULTADOS: O tempo de internação foi maior em pacientes com idade >65 anos (6 [1-75] dias vs. 4 [1-137] dias), assim como as complicações pós-operatórias (37/285; 13,0 por cento vs. 109/1627; 6,7 por cento; OR 2,1; IC95 por cento 1,40-3,09) e óbitos (15/285; 5,3 por cento vs. 34/1627; 2,1 por cento; OR 2,6; IC95 por cento 1,40-4,84). Em pacientes com índice de massa corporal < 24 kg/m², o tempo de internação (8 [1-75] dias vs. 4 [1-43] dias), complicações pós-operatórias (28/152; 18,4 por cento vs. 9/133; 6,8 por cento; OR 3,1; IC95 por cento 1,41-6,86) e reoperações (16/152; 10,5 por cento vs. 3/133; 2,2 por cento; OR 5,1; IC95 por cento 1,45-17,91) mostraram-se maiores. Utilizando-se como ponto de corte o índice de massa corporal de 18,5 kg/m², não houve diferenças. CONCLUSÕES: A morbimortalidade é alta em pacientes cirúrgicos de idade avançada. Nestes, o índice de massa corporal abaixo de 24 kg/m² mostrou melhor associação com a ocorrência de complicações...

BACKGROUND: Standard body mass index cut-off points for malnutrition are routinely used for adults independently of their age. The hypothesis of this study was that a cut-off point higher than the usual for the diagnosis of malnutrition might be more precise to access the nutritional risk of aged surgical patients. AIM: To evaluate the morbimortality in aged surgical patients and its association with nutritional status assessed by body mass index using either the standard and a higher cut-off point for malnutrition. PATIENTS AND METHODS: All patients admitted for operative procedures (n = 1,912) were allocated to either two groups: <65 years (n = 1,627) or >65 years old (n = 285). The body mass index was used to access the nutritional status. Two different cut-off points for malnutrition (18.5 or 24 kg/m²) were used in the group of older patients. Endpoints of the study were length of stay, morbidity and mortality. RESULTS: Length of stay was higher in patients over 65 years (6 [1-75] days vs. 4 [1-137] days). Both postoperative complications (37/285; 13.0 percent vs. 109/1627; 6,7 percent; OR 2,1; IC95 percent 1,40-3,09) and deaths (15/285; 5.3 percent vs. 34/1627; 2,1 percent; OR 2,6; IC95 percent 1,40-4,84) were most common in the older group. Using a higher cut-off (24 kg/m²), the length of stay (8 [1-75] days vs. 4 [1-43] days), postoperative complications (28/152; 18.4 percent versus 9/133; 6.8 percent; OR 3,1; IC95 percent 1.41-6.86) and re-operations (16/152; 10.5 percent versus 3/133; 2.2 percent; OR 5.1; IC95 percent 1.45-17.91) were greater in malnourished patients. However these correlations were not statistically significant with the cut-off point for malnutrition in 18.5 kg/m². CONCLUSIONS: Morbimortality is higher in surgical patients over 65 years old. In these, the cut-off point set in 24 kg/m² was most associated with the occurrence of postoperative complications, re-operations and length of stay.