Disparities in operative outcomes in patients with comorbid mental illness

doi:10.1016/j.surg.2017.09.029

Surgery

Volume 163, Issue 4, April 2018, Pages 667-671

https://doi.org/10.1016/j.surg.2017.09.029 Get rights and content

Abstract

Background

Patients with mental health disorders have worse medical outcomes and experience excess mortality compared with those without a mental health comorbidity. This study aimed to evaluate the relationship between mental health comorbidities and surgical outcomes.

Methods

This retrospective cohort study used the National Inpatient Sample (2009–2011) to select patients who underwent one of the 4 most common general surgery procedures (cholecystectomy and common duct exploration, colorectal resection, excision and lysis of peritoneal adhesions, and appendectomy). Patients with a concurrent mental health diagnosis were identified. Multivariable logistic regression examined outcomes, including prolonged length of stay, in-hospital mortality, and postoperative complications.

Results

Of the 579,851 patients included, 38,702 patients (6.7%) had a mental health diagnosis. Mood disorders were most prevalent (58.7%), followed by substance abuse (23.8%). After adjustment for confounders, including sex, race, number of comorbidities, admission status, open operations, insurance, and income quartile, we found that having a mental health diagnosis conferred a 40% greater odds of including prolonged length of stay (OR 1.41, P < .001) and increased odds of any complication (OR 1.18, P < .001). Odds of death were slightly less in the mental health diagnosis cohort.

Conclusions

General surgery patients with comorbid mental disease experience a greater incidence of postoperative complications and longer hospitalizations. Recognizing these disparate outcomes is the first step in understanding how to optimize care for this frequently marginalized population.

Introduction

It is estimated that almost half of Americans will meet diagnostic criteria for a mental health disorder at some point in their life, and nearly 1 in 8 will be diagnosed with 2 or more mental health disorders.¹ Patients with a mental health diagnosis are at an increased risk of developing medical comorbidities such as coronary artery disease2, 3 and lifestyle-related cancers such as lung cancer.⁴

Patients with comorbid mental disease have worse outcomes when treated for medical conditions.⁵ Patients with mental health disorders experience worse oncologic outcomes,⁴ inferior chronic disease management,⁵ and even excess mortality compared with patients without a mental health diagnosis.6, 7 To date, there is a paucity of literature examining the impact of mental health diagnoses as patients recover from surgery.

The primary aim of this study was to evaluate the relationship between mental health comorbidities and operative outcomes. We hypothesized that patients with mental health comorbidities experience worse surgical outcomes compared with those without a mental health diagnosis.

Section snippets

Data sources and patient population

We conducted a retrospective cohort study using the 2009–2011 National Inpatient Sample database.⁸ All patients aged 18–90 who underwent one of 4 most common general surgery procedures (cholecystectomy and common duct exploration, colorectal resection, excision and lysis of peritoneal adhesions, and appendectomy) were included as identified by the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ).⁹ Procedure categories were defined by the

Results

We identified 579,851 patients who underwent one of the 4 most common general surgery procedures in the United States between 2009 and 2011. Cholecystectomy and bile duct exploration represented 40.7% of the cohort (n = 236,193), followed by colorectal resection (28.7%; n = 166,244), appendectomy (21.4%; n = 124,317), and excision and lysis of peritoneal adhesions (9.2%; n = 53,097). Of the 579,851 patients, 38,702 (6.67%) had a concurrent mental health diagnosis on admission. Of these, mood

Discussion

This study shows that for patients undergoing common general surgery procedures, the presence of a mental health diagnosis is associated with significantly prolonged postoperative hospital stays and increased odds of postoperative complications. The type of mental health comorbidity and absolute number of mental health comorbidities affects the odds of experiencing an adverse event. Patients with schizophrenia, substance abuse, and 3 or more mental health diagnoses experienced the greatest

Conclusion

Patients with comorbid mental health conditions who undergo the most common general surgery procedures experience a greater incidence of postoperative complications and longer hospitalizations. Recognizing these disparate outcomes is the first step in understanding how to optimize care for this frequently marginalized and medically vulnerable population.

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Cited by (33)

Longer hospitalizations, more complications, and greater readmissions for patients with comorbid psychiatric disorders undergoing pulmonary lobectomy
2024, Journal of Thoracic and Cardiovascular Surgery
To examine the influence of comorbid psychiatric disorders (PSYD) on postoperative outcomes in patients undergoing pulmonary lobectomy.
A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2016 to 2018 was performed. Patients with lung cancer with and without psychiatric comorbidities who underwent pulmonary lobectomy were collated and analyzed (International Classification of Diseases, 10th Revision, Clinical Modification Mental, Behavioral and Neurodevelopmental disorders [F01-99]). The association of PSYD with complications, length of stay, and readmissions was assessed using a multivariable regression analysis. Additional subgroup analyses were performed.
A total of 41,691 patients met inclusion criteria. Of these, 27.84% (11,605) of the patients had at least 1 PSYD. PSYD was associated with a significantly increased risk of postoperative complications (relative risk, 1.041; 95% CI, 1.015-1.068; P = .0018), pulmonary complications (relative risk, 1.125; 95% CI, 1.08-1.171; P < .0001), longer length of stay (PSYD mean, 6.79 days and non-PSYD mean, 5.68 days; P < .0001), higher 30-day readmission rate (9.2% vs 7.9%; P < .0001), and 90-day readmission rate (15.4% vs 12.9%; P < .007). Among patients with PSYD, those with cognitive disorders and psychotic disorders (eg, schizophrenia) appear to have the highest rates and risks of postoperative morbidity and in-hospital mortality.
Patients with lung cancer with comorbid psychiatric disorders undergoing lobectomy experience worse postoperative outcomes with longer hospitalization, increased rates of overall and pulmonary complications, and greater readmissions suggesting potential opportunities for improved psychiatric care during the perioperative period.
The Association of Mental Illness With Outcomes of Emergency Surgery for Bowel Obstruction
2023, Journal of Surgical Research
Bowel obstruction is one of the most common surgical emergencies. The management of SBO is variable and influenced by numerous confounding factors. Recent studies have identified mental health as a health disparity that affects surgical outcomes. We aim to assess whether mental illness is a health disparity and its association with postoperative complications and secondary outcomes for bowel obstruction in Emergency General Surgery (EGS).
This was a retrospective study utilizing the National Inpatient Sample. Individuals aged 18-64 who underwent emergency adehesiolysis or bowel resection from 2015 to 2017 were identified. Postoperative complications, in-hospital mortality, length of stay, and total cost for surgical patients with and without mental illness were recorded. Univariate and multivariate analyses were used to evaluate the association between mental health and bowel obstruction.
20,574 patients who underwent surgery for bowel obstruction were identified. 3756 of these patients had mental illness and 16,998 patients did not. Patients with mental illness did not have significantly worse outcomes compared to patients without mental illness. Among 3576 patients with mental illness, sex, race, patient location, insurance, location/teaching status of hospital, hospital control and procedure type were significant predictors of prolonged length of stay, higher cost, and increased postoperative complications.
Mental health does not appear to be a health disparity in outcomes for bowel obstruction procedures. However, the intersection of mental health with race and insurance status predicts worse outcomes. This essential area should be further explored to determine how marginalized populations are affected in emergency surgical care.
Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study
2023, Journal of Surgical Research
Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively.
EGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal–Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models.
Among 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001).
HFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.
Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis
2023, Journal of Surgical Research
Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture.
The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS.
Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals.
Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.
Shared Decision Making in the Geriatric Surgery Verification Program: Assessing Baseline Performance
2023, Journal of Pain and Symptom Management
As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients’ goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown.
To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence.
Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes.
A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00–1.68), undergoing colectomy (OR 2.82; 95% CI 2.15–3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14–2.09]).
Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.
The impact of schizophrenia spectrum disorder, bipolar disorder and borderline personality disorder on radiotherapy treatment and overall survival in cancer patients: A matched pair analysis
2023, Clinical and Translational Radiation Oncology
The effect of a psychiatric disorder (PD) on the choice of radiotherapy regimens and subsequent cancer control outcomes is largely unknown. In this study, we evaluated differences in radiotherapy regimens and overall survival (OS) between cancer patients with a PD in comparison with a control population of patients without a PD.
Referred patients with a PD (i.e. schizophrenia spectrum disorder, bipolar disorder or borderline personality disorder) were included through a text-based search of the electronic patient database of all the patients that received radiotherapy between 2015 and 2019 at a single centre. Each patient was matched to a patient without a PD. Matching was based on cancer type, staging, performance score (WHO/KPS), non-radiotherapeutic cancer treatment, gender and age. Outcomes were the amount of fractions received, total dose, and OS.
88 patients with PD were identified; 44 patients with schizophrenia spectrum disorder, 34 with bipolar disorder, and 10 with borderline personality disorder. Matched patients without a PD showed similar baseline characteristics. No statistically significant difference was observed regarding the number of fractions with a median of 16 (interquartile range [IQR] 3–23) versus 16 (IQR 3–25), respectively (p = 0.47). Additionally, no difference in total dose was found. Kaplan-Meier curves showed a statistically significant difference in OS between the patients with a PD versus those without a PD, with 3-year OS rates of 47 % versus 61 %, respectively (hazard ratio 1.57, 95 % confidence interval 1.05–2.35, p = 0.03). No clear differences in causes of death were observed.
Cancer patients referred for radiotherapy with schizophrenia spectrum disorder, bipolar disorder or borderline personality disorder receive similar radiotherapy schedules for a variety of tumour types but attain worse survival.

View all citing articles on Scopus

: No financial support was provided for this study.

: Abstract presented at the 2017 Academic Surgical Congress (Abstract number 72.10).

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HealthcarePresented at the Academic Surgical Congress 2017Disparities in operative outcomes in patients with comorbid mental illness

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Data sources and patient population

Results

Discussion

Conclusion

Lancet Oncol

J Psychosom Res

J Psychosom Res

J Subst Abuse Treat

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication

Arch Gen Psychiatry

Schizophrenia: medical illness, mortality, and aging

Int J Psychiatry Med

Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review

Psychosom Med

Quality of medical care and excess mortality in older patients with mental disorders

Arch Gen Psychiatry

Mortality and medical comorbidity among psychiatric patients: a review

Psychiatr Serv

Mortality and medical comorbidity among patients with serious mental illness

Psychiatr Serv

HCUP NIS Database Documentation

Most Frequent Operating Room Procedures Performed in U.S. Hospitals, 2003–2012

HCUP CCS

Healthcare
Presented at the Academic Surgical Congress 2017
Disparities in operative outcomes in patients with comorbid mental illness