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Obesity Increases Risk-Adjusted Morbidity, Mortality, and Cost Following Cardiac Surgery.

ABSTRACT: Despite the epidemic rise in obesity, few studies have evaluated the effect of obesity on cost following cardiac surgery. We hypothesized that increasing body mass index (BMI) is associated with worse risk-adjusted outcomes and higher cost.Medical records for 13 637 consecutive patients who underwent coronary artery bypass grafting (9702), aortic (1535) or mitral (837) valve surgery, and combined valve-coronary artery bypass grafting (1663) procedures were extracted from a regional Society of Thoracic Surgeons certified database. Patients were stratified by BMI: normal to overweight (BMI 18.5-30), obese (BMI 30-40), and morbidly obese (BMI >40). Differences in outcomes and cost were compared between BMI strata and also modeled as a continuous function of BMI with adjustment for preoperative risk using Society of Thoracic Surgeons predictive risk indices. Morbidly obese patients incurred nearly 60% greater observed mortality than normal weight patients. Moreover, morbidly obese patients had greater than 2-fold increase in renal failure and 6.5-fold increase in deep sternal wound infection. After risk adjustment, a significant association was found between BMI and mortality (P<0.001) and major morbidity (P<0.001). The risk-adjusted odds ratio for mortality for morbidly obese patients was 1.57 (P=0.02) compared to normal patients. Importantly, risk-adjusted total hospital cost increased with BMI, with 17.2% higher costs in morbidly obese patients.Higher BMI is associated with increased mortality, major morbidity, and cost for hospital care. As such, BMI should be more strongly considered in risk assessment and resource allocation.

SUBMITTER: Ghanta RK

PROVIDER: S-EPMC5523989 | biostudies-other | 2017 Mar

REPOSITORIES: biostudies-other

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Project description:BackgroundAlcohol and obesity synergise to increase the risk of liver-related mortality. We examined the influence of adiposity on clinical outcomes in alcoholic hepatitis (AH) and the underlying inflammatory crosstalk between adipose tissue (AT) and the liver.MethodsA cohort of 233 patients with AH from the UK and USA provided data to analyse the effects of obesity in AH. Body mass index was corrected for the severity of ascites, termed cBMI. Inflammatory and metabolic profiling was undertaken by proteome analysis of human serum samples. The effect of alcohol on adipose tissue and CXCL11 expression was studied in 3 T3-derived adipocytes and in mice using the high-fat diet-plus-binge ethanol model.FindingsObesity was common amongst patients with AH, seen in 19% of individuals. Obesity (HR 2.22, 95%CI 1.1-4.3, p = .022) and underweight (HR 2.38, 1.00-5.6, p = .049) were independently associated with mortality at 3 months. Proteome analysis demonstrated multiple metabolic and inflammatory factors differentially expressed in obese AH verse lean AH, with CXCL11 being the most elevated factor in obese AH. In vitro analysis of cultured adipocytes and in vivo analysis of mouse models showed that alcohol induced CXCL11 expression in AT, but not in liver.InterpretationObesity is common in AH and associated with a greater than two-fold increase in short-term mortality. Obese AH is associated with a different inflammatory phenotype, with the greatest elevation in CXCL11. These data confirm that adiposity is clinically important in acute alcohol-related liver disease and illustrate the adipose-liver inflammatory axis in AH. FUND: This work was supported in part by an EASL Sheila Sherlock Physician Scientist Fellowship. The funder played no role in gathering or analysing data or writing the manuscript. This paper presents independent research supported by the NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Project description:OBJECTIVE:To develop a postoperative mortality case-mix adjustment model to facilitate assessment of cardiac ICU quality of care, and to describe variation in adjusted cardiac ICU mortality across hospitals within the Pediatric Cardiac Critical Care Consortium. DESIGN:Observational analysis. SETTING:Multicenter Pediatric Cardiac Critical Care Consortium clinical registry. PARTICIPANTS:All surgical cardiac ICU admissions between August 2014 and May 2016. The analysis included 8,543 admissions from 23 dedicated cardiac ICUs. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We developed a novel case-mix adjustment model to measure postoperative cardiac ICU mortality after congenital heart surgery. Multivariable logistic regression was performed to assess preoperative, intraoperative, and immediate postoperative severity of illness variables as candidate predictors. We used generalized estimating equations to account for clustering of patients within hospital and obtain robust SEs. Bootstrap resampling (1,000 samples) was used to derive bias-corrected 95% CIs around each predictor and validate the model. The final model was used to calculate expected mortality at each hospital. We calculated a standardized mortality ratio (observed-to-expected mortality) for each hospital and derived 95% CIs around the standardized mortality ratio estimate. Hospital standardized mortality ratio was considered a statistically significant outlier if the 95% CI did not include 1. Significant preoperative predictors of mortality in the final model included age, chromosomal abnormality/syndrome, previous cardiac surgeries, preoperative mechanical ventilation, and surgical complexity. Significant early postoperative risk factors included open sternum, mechanical ventilation, maximum vasoactive inotropic score, and extracorporeal membrane oxygenation. The model demonstrated excellent discrimination (C statistic, 0.92) and adequate calibration. Comparison across Pediatric Cardiac Critical Care Consortium hospitals revealed five-fold difference in standardized mortality ratio (0.4-1.9). Two hospitals had significantly better-than-expected and two had significantly worse-than-expected mortality. CONCLUSIONS:For the first time, we have demonstrated that variation in mortality as a quality metric exists across dedicated cardiac ICUs. These findings can guide efforts to reduce mortality after cardiac surgery.

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Obesity Increases Risk-Adjusted Morbidity, Mortality, and Cost Following Cardiac Surgery.

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