Comorbidities Increase Postoperative Mortality Risk for Patients with Inflammatory Bowel Disease

Data from a large administrative study of patients with inflammatory bowel disease (IBD) hospitalized for an IBD-related surgical procedure show that comorbidities increase the likelihood of postoperative death. As the number of comorbidities increases, so does the risk of death, length of hospitalization, and hospital costs. Authors of the study said their findings might be useful in developing standards of practice for preoperatively assessing risk in patients with IBD, particularly those with comorbidities, with the goal of improving postoperative outcomes [Arch Surg. 2011;146(8):959-964]. The researchers reviewed discharge summaries for 35,588 hospitalizations of adults 18 to 80 years of age (median, 42 years) with IBD who underwent elective, urgent, or emergency IBD-related surgery at a US hospital from January 1995 through December 2005. The patients had Crohn’s disease (67.3%) or colitis (32.7%); 48.2% were men, 63.7% were white, and 69.3% had private health insurance. The primary objective was to establish the probability of postoperative death. Investigators also examined consumption of health resources, based on length of stay (LOS) and hospital charges (adjusted for inflation to 2005 dollars). To evaluate how various comorbidities affect outcomes, they applied the Elixhauser comorbidity algorithm, which has been validated for IBD patients. The rate of in-hospital mortality was 1.9%, the median LOS was 8 days, and median hospital charges totaled $29,150. Comorbidities affecting >10% of the population included fluid and electrolyte disorders (17.46%), hypertension (13.01%), and iron deficiency anemia (11.38%). Although comorbidities such as congestive heart failure, cardiac arrhythmias, liver disease, and renal failure were less prevalent, they were greater predictors of postoperative death. Mortality risk was also higher for patients with prior thrombosis or embolism, yet lower for patients with nonmetastatic solid tumors, lymphoma, or colon cancer. The authors theorized that postoperative mortality for patients with colon cancer might be lower because surgery is typically delayed until IBD is in remission. Secondary analyses determined that coagulopathy and fluid and electrolyte disorders imparted higher mortality risk and required more healthcare resources. Conversely, patients with hypertension and hypothyroidism had lower mortality rates, shorter hospitalizations, and lower hospital costs. The more comorbid conditions a patient had, the more likely he or she was to die in-hospital after surgery. The mortality risk for patients with no comorbid conditions was 0.4%, compared with 7.9% of the 10% of patients who had ≥3 comorbidities. Older patients with more comorbidities had the highest mortality risk, regardless of whether their procedure was performed on an emergency or elective basis. Among patients with at least 2 comorbid conditions who had emergency surgery, those 65 to 80 years of age had a 20.6% probability of postoperative death compared with 1.0% for individuals 18 to 34 years of age and 3.4% for those 35 to 64 years of age. For patients with ≥2 comorbidities who had elective surgery, the probability of postoperative death was 7.7% for those 65 to 80 years of age versus 0.3% for patients 18 to 34 years of age and 1.7% for individuals 35 to 64 years of age. Individuals 18 to 34 years of age were least likely to have any comorbidities and had the lowest postoperative mortality risk, which was 0.4% for those undergoing emergency surgery and 0.1% for individuals having an elective procedure. Patients undergoing colectomy after emergency admission were significantly more likely to die postoperatively, especially elderly individuals with several comorbidities. Higher numbers of comorbidities were also associated with longer hospitalizations and greater hospital costs. The median LOS for patients with no comorbidities was 7 days, costing an average of $24,598. This increased to a median of 8 days and $30,638 for patients with 1 comorbidity and 10 days and $37,538 for patients with 2 comorbidities. Patients with ≥3 comorbidities were hospitalized an average of 12 days, accumulating a median of $46,466 in expenses. The authors noted that preoperative comorbidities are common in people with IBD, suggesting a need for preoperative risk stratification. “Those patients with IBD who have multiple comorbidities should be reviewed by a gastroenterologist and a colorectal surgeon to evaluate the appropriate timing of an operation and to ensure optimization of medical management,” they concluded.