Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis

期刊论文
发表日期：

2024年5月24日

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Nishit Patel,
Janak Bahirwani,
Krishna Bodrya,
Dhruvanshu Patel,
Yecheskel Schneider

摘要

Background

Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort.

Method

We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality.

Results

Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table 1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65–1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table 2).

Characteristics

Acute pancreatitis with High HES Frailty score (> 5, intermediate + high)

Acute pancreatitis with low HES Frailty score (< 5)

P-value

N = 1,267,744

N = 728,953 (57.5%)

N = 538,781 (42.5%)

Age

Mean years (Mean ± SD)

64.8 ± 12.6

58.6 ± 9.5

< 0.001

Gender

< 0.001

Male

59.1%

52.3%

Female

40.9%

47.7%

*Missing—475

Age groups

< 0.001

18–44

3.7%

14.3%

45–64

48%

52.9%

65–84

32.2%

28.7%

≥ 85

16.1%

4.1%

Race

< 0.001

Caucasians

67.4%

61.9%

African Americans

9.6%

16.8%

Others

23%

21.3%

*Missing—10

Insurance type

< 0.001

Medicare

40.9%

36.3%

Medicaid

17.2%

24.3%

Private

31.8%

27.9%

Other

9.9%

11.4%

*Missing—75

Active smoking

32.7%

37.9%

0.005

Biliary Stone

36.2%

16.7%

< 0.001

Admission Type

< 0.001

Emergent

93.7%

94.3%

Elective

6.3%

5.7%

*Missing—2880

Hospital ownership/control

< 0.001

Rural

7.8%

10%

Urban nonteaching

26.3%

26.6%

Urban teaching

65.9%

63.4%

Outcomes

Acute pancreatitis with High HES Frailty score (> 5, intermediate + high)

Acute pancreatitis with low HES Frailty score (< 5)

P-value

In-hospital mortality

*Missing—920

4.3%

2.5%

< .0001

1.72(1.65–1.80)

< .0001

Length of stay, days (Median,IQR)

6(3–8)

4(2–6)

< .0001

Total hospitalization cost, $ (Median,IQR)

14,412(8843–20,216)

10,193(6840–13,842)

< .0001

In-Hospital Complications

ARDS

0.4%

0.3%

0.08

Ventilator dependence respiratory failure

0.23%

0.29%

0.25

Septicemia

15.2%

9.6%

< .0001

Septic Shock

6.1%

2.9%

< .0001

AKI

24.8%

14.9%

< .0001

Disposition

< .0001

Discharge to home

58.9%

74.9%

Transfer other: includes Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility

17.1%

8.6%

Home health care

11.5%

8.1%

Against medical advice (AMA)

1.6%

3.4%

*Missing—920

Conclusion

Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.