Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes

Abstract

Importance: Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention.

Objective: To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin.

Design, setting, and participants: This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018.

Exposures: Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure.

Main outcomes and measures: All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score-matched cohort.

Results: Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score-matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score-matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality (adjusted HR, 0.72 [95% CI, 0.55-0.95]; ARR, 1.28% [95% CI, 0.26-2.31]) and hazard of readmission, with mortality as a competing risk at both 30 days (ARR, 2.09% [95% CI, 0.35-3.82]; sub-HR, 0.84 [95% CI, 0.72-0.98]) and 90 days (ARR, 2.78% [95% CI, 0.62-4.95]; sub-HR, 0.86 [95% CI, 0.77-0.97]). Preoperative inflammation was reduced in those with metformin prescriptions compared with those without (mean neutrophil to leukocyte ratio, 4.5 [95% CI, 4.3-4.6] vs 5.0 [95% CI, 4.8-5.3]; P < .001). E-value analysis suggested robustness to unmeasured confounding.

Conclusions and relevance: This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.

Figure 1.. Flow Diagram of Patients in the Propensity Score–Matched Cohorts

^aExclusion criteria were not mutually exclusive. ^bNo preoperative estimated glomerular filtration rate (eGFR) available in the 180 days before the operation was automatically abstracted from within the electronic health record. ^cPatients for whom metformin therapy was not currently recommended.

Figure 2.. Kaplan-Meier Survival Curves for Postoperative Day 90 (A) and at Year 5 (B) in the Propensity Score–Matched Cohorts

Patients who did not die and were lost to follow-up within the postoperative window were censored at their last contact date. Those censored at time 0 had no postoperative encounter with the health care system after hospital discharge.

Figure 3.. Hazard of 90-Day Mortality in Prespecified Subgroups in the Propensity Score–Matched Cohorts

mARR indicates matched cohort absolute risk reduction; mHR, matched cohort hazard ratios (HRs). ^aTotal number (%) of deaths and patients at 90 days and associated absolute risk reduction in the prespecified subgroups within the propensity score–matched cohorts. ^bHRs compared those with preoperative metformin prescriptions to those without prescriptions in the propensity score–matched cohorts.