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. 2020 Jan;10(1):22-28.
doi: 10.1177/1941874419848590. Epub 2019 May 7.

A Multilevel Analysis of Surgical Category and Individual Patient-Level Risk Factors for Postoperative Stroke

Benjamin R Kummer  1 , Rebecca Hazan  2 , Alexander E Merkler  1   3 , Hooman Kamel  1   3 , Joshua Z Willey  4 , William Middlesworth  5 , Shadi Yaghi  6 , Randolph S Marshall  4 , Mitchell S V Elkind  4   7 , Amelia K Boehme  4   7
Affiliations

A Multilevel Analysis of Surgical Category and Individual Patient-Level Risk Factors for Postoperative Stroke

Benjamin R Kummer et al. Neurohospitalist. 2020 Jan.

Abstract

Background and purpose: Many studies supporting the association between specific surgical procedure categories and postoperative stroke (POS) do not account for differences in patient-level characteristics between and within surgical categories. The risk of POS after high-risk procedure categories remains unknown after adjusting for such differences in patient-level characteristics.

Methods: Using inpatients in the American College of Surgeons National Surgical Quality Initiative Program database, we conducted a retrospective cohort study between January 1, 2000, and December 31, 2010. Our primary outcome was POS within 30 days of surgery. We characterized the relationship between surgical- and individual patient-level factors and POS by using multivariable, multilevel logistic regression that accounted for clustering of patient-level factors with surgical categories.

Results: We identified 729 886 patients, 2703 (0.3%) of whom developed POS. Dependent functional status (odds ratio [OR]: 4.11, 95% confidence interval [95% CI]: 3.60-4.69), history of stroke (OR: 2.35, 95%CI: 2.06-2.69) or transient ischemic attack (OR: 2.49 95%CI: 2.19-2.83), active smoking (OR: 1.20, 95%CI: 1.08-1.32), hypertension (OR: 2.11, 95%CI: 2.19-2.82), chronic obstructive pulmonary disease (OR: 1.39 95%CI: 1.21-1.59), and acute renal failure (OR: 2.35, 95%CI: 1.85-2.99) were significantly associated with POS. After adjusting for clustering, patients who underwent cardiac (OR: 11.25, 95%CI: 8.52-14.87), vascular (OR: 4.75, 95%CI: 3.88-5.82), neurological (OR: 4.60, 95%CI: 3.48-6.08), and general surgery (OR: 1.40, 95%CI: 1.15-1.70) had significantly greater odds of POS compared to patients undergoing other types of surgical procedures.

Conclusions: Vascular, cardiac, and neurological surgery remained strongly associated with POS in an analysis accounting for the association between patient-level factors and surgical categories.

Keywords: cerebrovascular disorders; clinical specialty; cluster analysis; outcomes; postoperative stroke; stroke; stroke and cerebrovascular disease; techniques.

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Conflict of interest statement

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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