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Leading Comorbidity associated with 30-day post-anesthetic mortality in geriatric surgical patients in Taiwan: a retrospective study from the health insurance data

  • Chun-Lin Chu1, 2,
  • Hung-Yi Chiou3,
  • Wei-Han Chou4,
  • Po-Ya Chang3,
  • Yi-You Huang1 and
  • Huei-Ming Yeh4Email author
BMC GeriatricsBMC series – open, inclusive and trusted201717:245

https://doi.org/10.1186/s12877-017-0629-7

Received: 28 March 2017

Accepted: 8 October 2017

Published: 24 October 2017

Abstract

Background

Elderly patients with aged physical status and increased underlying disease suffered from more postoperative complication and mortality. We design this retrospective cohort study to investigate the relationship between existing comorbidity of elder patients and 30 day post-anesthetic mortality by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) from Health Insurance Database.

Methods

Patients aged above 65 years old who received anesthesia between 2000 and 2010 were included from 1 million Longitudinal Health Insurance Database in (LHID) 2005 in Taiwan. We use age, sex, type of surgery to calculate propensity score and match death group and survival one with 1:4 ratio (death: survival = 1401: 5823). Multivariate logistic model with stepwise variable selection was employed to investigate the factors affecting death 30 days after anesthesia.

Results

Thirty seven comorbidities can independently predict the post-anesthetic mortality. In our study, the leading comorbidities predict post-anesthetic mortality is chronic renal disease (OR = 2.806), acute myocardial infarction (OR = 4.58), and intracranial hemorrhage (OR = 3.758).

Conclusions

In this study, we present the leading comorbidity contributing to the postoperative mortality in elderly patients in Taiwan from National Health Insurance Database. Chronic renal failure is the leading contributing comorbidity of 30 days mortality after anesthesia in Taiwan which can be explained by the great number of hemodialysis and prolong life span under National Taiwan Health Insurance. Large scale database can offer enormous information which can help to improve quality of medical care.

Keywords

ComorbidityPost-anesthesia mortality

Background

Increased life expectancy, improvement of anesthesia safety and less invasive surgical techniques have made greater number of geriatric patients receive surgical intervention. With aged physical status and increased underlying disease, the risk of anesthesia and postoperative complication and mortality is much higher than other populations [1, 2].

The main four factors of surgical risk and outcome in patients older than 65 years old are age,physiologic status,coexisting disease, and type of procedure [3, 4]. Earlier studies suggest that anesthetic complications are related to age and some studies also have corroborated an association of mortality and morbidity with American Society of Anesthesiologists physical status (ASA-PS) scores. The surgical procedure itself significantly influence postoperative risk and it can be classified to low, intermediate, and high-risk surgery [5].

The ASA-PS classification introduced to clinical practice since 1941 was used worldwide to quantify the amount of physiological reserve that a patient possesses when assessed before a surgical procedure. This classification is validated as a reliable independent predictor of medical complications and mortality following surgery in peer review articles [6, 7]. However, the ASA-PS scale has unreliability due to its inherent subjectivity which resulted in different ASA class rated in one patient by different anesthesiologists [8]. It is useful but lack of scientific precision.

To date, national health insurance database in Taiwan has recruited most patients’ information and medical record for more than 10 years. Several studies have been published by using the reimbursement claims data of Taiwan’s national Health Insurance [911]. We design this retrospective cohort study to investigate the relationship of existing comorbidity of geriatric patients who came for anesthesia with 30 day post-anesthetic mortality rate by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). We hope to investigate the impact of different underlying comorbidity of the geriatric patient on post-anesthesia mortality.

Methods

Data base

Taiwan’s National Health Insurance was put into practice since 1995 and covered more than 22.6 million residents in Taiwan. Taiwan’s National Health Research Institutes established a National Health Research Database which record all in-patient and out-patient medical services for research [9]. This study used the 1 million Longitudinal Health Insurance Database in 2005 (LHID), which means 1 million patients were randomly enrolled in 2005 and the longitudinal database included all the issue from 2000 to 2010. The database was decoded with patient identifications to protect patients’ privacy and scrambled for further public access. This study was approved by National Taiwan University Hospital Ethics Committee (201411078RINC) and inform consent was waived.

Study sample

The study sample is the patients aged above 65 years old and received anesthesia between 2000 and 2010. There were 420,848 index surgery requiring anesthesia in this period, including general anesthesia 304,308 times, brachial plexus block 5518 times, spinal anesthesia 85,888 times, and epidural anesthesia 2,5134 times. We defined mortality as death date appeared within 30 days after index surgery whether in hospital or not. There were 2324 death and 418,524 survival after index surgery. Due to tremendous difference in population, we use age, sex, type of surgery to calculate propensity score [12, 13] and match death and survival group with 1:4. Among them, there were 6729 patients aged above 65 years old and 1401 patients were dead (Fig. 1).
Fig. 1

Flow chart of study design

Key variable of interest

We use International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) appeared 2 years before index surgery in our database as comorbidity. The definition of comorbidity means the patient was diagnosed for more than 3 times and the interval was more than 28 days which including ischemic heart disease, hypertension, heart failure, vascular disease, respiratory disease, disease of liver and biliary tract, disease of GI system, urinary disease, endocrine disease, musculoskeletal disease, infectious disease, CVA or trauma, cancer, other disease..(Additional file 1) Due to disease categorization is complex, we therefore aggregated codes into disease group to resemble clinical pre-anesthetic usage. This process was conducted independently by three anesthesiologists.

Statistical analysis

The difference of comorbidity in death and survival group 30 days after index surgery was analyzed by Chi-Square test. We use conditional logistic regression to correct age, gender, type of surgery and other comorbidity, then analysis the correlation of comorbidity with death. Multivariate logistic model with stepwise variable selection [14] was employed to investigate the factors affecting death 30 days after anesthesia. We perform calculation by SAS statistical package (SAS System for Windows, Version 9.3; SAS Institute Inc., Cary, NC).

Results

More than one hundred codes were given out when we count all the comorbidity ICD-9 code in death group. Seventy three codes were selected after aggregation by expertise. (Additional file 1) All the comorbidity was compared by chi square test under 1:4 ratio by matching age, sex, type of surgery as Table 1 listed. Age and sex were both statistically significant after propensity score matching. The crude odds ratio and adjusted odds of each comorbidity (Table 2) was counted and then 37 leading comorbidities (Table 3) which can independently predict 30 days post-anesthetic mortality in geriatric patients were ranked by multivariate logistic model with stepwise variable selection. In our study, the leading comorbidities predict post-anesthetic mortality is chronic renal disease, acute myocardial infarction, and intracerebral hemorrhage.
Table 1

Correlation analysis of comorbidity and mortality in more than 65-year-old patients, N = 6729 (match 1:4)

Comorbidity

Non-Death

(N = 5823)

Death

(N = 1401)

P

n

%

n

%

Age(mean,sd)

76.72

7.08

78.08

7.41

<.0001

Sex(Male)

3563

66.87

855

61.03

<.0001

Ischemic heart disease

 Acute myocardial infarction

66

1.24

68

4.85

<.0001

 Coronary atherosclerosis of native coronary artery

661

12.41

251

17.92

<.0001

 Hypertension

1556

29.2

616

43.97

<.0001

Heart failure

 Heart failure

232

4.35

155

11.06

<.0001

 Cardiogenic shock

106

1.99

66

4.71

<.0001

Vascular disease

 Arterial embolism and thrombosis of lower extremity

39

0.73

26

1.86

0.0002

 Gangrene

106

1.99

66

4.71

<.0001

Respiratory disease

 Pneumonia, organism unspecified

339

6.36

165

11.78

<.0001

 Pneumonitis due to inhalation of food or vomitus

61

1.14

18

1.28

0.7694

 Empyema, without mention of fistula

13

0.24

9

0.64

0.0393

 Chronic bronchitis

471

8.84

162

11.56

0.0022

 Pleurisy, unspecified pleural effusion

27

0.51

12

0.86

0.1812

 Pulmonary insufficiency following trauma and surgery

263

4.94

88

6.28

0.0515

Disease of liver and biliary tract

 Chronic liver disease and cirrhosis

260

4.88

97

6.92

0.003

Disease of GI system

 Gastric ulcer, chronic or unspecified with hemorrhage

303

5.69

141

10.06

<.0001

 Acute vascular insufficiency of intestine

21

0.39

30

2.14

<.0001

 Intestinal or peritoneal adhesions with obstruction

133

2.5

52

3.71

0.0171

 Hemorrhage of gastrointestinal tract

77

1.45

64

4.57

<.0001

 Gastric ulcer,chronic or unspecified with perforation

303

5.69

141

10.06

<.0001

 Duodenal ulcer, chronic or unspecified with perforation

164

3.08

93

6.64

<.0001

 Peptic ulcer, site unspecified, chronic or unspecified with perforation

482

9.05

181

12.92

<.0001

 Acute appendicitis, with generalized peritonitis

60

1.13

11

0.79

0.3348

 Peritonitis

9

0.17

20

1.43

<.0001

 Perforation of intestine

59

1.11

37

2.64

<.0001

Urinary disease

 Tuberculosis of ureter, tubercle bacilli found

52

0.98

48

3.43

<.0001

 Unspecified hypertensive renal disease with renal failure

58

1.09

27

1.93

0.0180

 Acute renal failure

50

0.94

28

2

0.0016

 Chronic renal failure

206

3.87

159

11.35

<.0001

 Hydronephrosis

31

0.58

9

0.64

0.9465

 Calculus of ureter

227

4.26

27

1.93

<.0001

 Urinary tract infection, site not specified

662

12.42

239

17.06

<.0001

 Hypertrophy (benign) of prostate

948

17.79

214

15.27

0.0293

 Endocrine disease

845

15.86

377

26.91

<.0001

Musculoskeletal disease

 Decubitus ulcer

94

1.76

50

3.57

<.0001

 Spinal stenosis, lumbar region

1091

20.48

329

23.48

0.0156

 Pathologic fracture of vertebrae

334

6.27

101

7.21

0.2253

 Fracture of intertrochanteric section of femur

388

7.28

157

11.21

<.0001

Infectious disease

 Unspecified septicemia

62

1.16

12

0.86

0.4026

 Necrotizing fasciitis

93

1.75

42

3

0.0041

 Bacteremia

41

0.77

12

0.86

0.8744

CVA or trauma

 Obstructive hydrocephalus

91

1.71

28

2

0.5349

 Other conditions of brain

16

0.3

9

0.64

0.1039

 Subarachnoid hemorrhage

16

0.3

25

1.78

<.0001

 Intracerebral hemorrhage

106

1.99

82

5.85

<.0001

 Subdural hemorrhage

70

1.31

14

1

0.4189

 Unspecified cerebral artery occlusion with cerebral infarction

382

7.17

170

12.13

<.0001

 Other shock without mention of trauma

106

1.99

66

4.71

<.0001

 Other and unspecified cerebral laceration

24

0.45

16

1.14

0.0051

 Subarachnoid hemorrhage following injury

128

2.4

84

6

<.0001

 Other and unspecified intracranial hemorrhage

20

0.38

13

0.93

0.0155

 Fracture of vault of skull, closed

6

0.11

6

0.43

0.0327

 Fracture of base of skull, closed

11

0.21

12

0.86

0.0006

Cancer

 Malignant neoplasm of tongue, unspecified

10

0.19

1

0.07

0.5570

 Malignant neoplasm of cheek mucosa

19

0.36

7

0.5

0.5989

 Malignant neoplasm of nasopharynx, unspecified

8

0.15

3

0.21

0.8761

 Malignant neoplasm of hypopharynx, unspecified

8

0.15

1

0.07

0.7588

 Malignant neoplasm of upper third of esophagus

12

0.23

9

0.64

0.0263

 Malignant neoplasm of pyloric antrum of stomach

66

1.24

29

2.07

0.0265

 Malignant neoplasm of sigmoid colon

175

3.28

52

3.71

0.4810

 Malignant neoplasm of recto sigmoid junction

125

2.35

33

2.36

1.0000

 Malignant neoplasm of liver, primary

59

1.11

43

3.07

<.0001

 Malignant neoplasm of head of pancreas

16

0.3

13

0.93

0.0031

 Malignant neoplasm of upper lobe, bronchus or lung

52

0.98

48

3.43

<.0001

 Malignant neoplasm of female breast, unspecified

47

0.88

5

0.36

0.0678

 Malignant neoplasm of cervix uteri, unspecified

29

0.54

4

0.29

0.3082

 Malignant neoplasm of ovary

2

0.04

3

0.21

0.1079

 Malignant neoplasm of prostate

103

1.93

23

1.64

0.5449

 Malignant neoplasm of bladder, part unspecified

131

2.46

33

2.36

0.9000

 Secondary and unspecified malignant neoplasm of lymph nodes of head, face

6

0.11

2

0.14

1.0000

 Secondary malignant neoplasm of lung

21

0.39

11

0.79

0.0940

 Secondary malignant neoplasm of skin

26

0.49

25

1.78

<.0001

Other diseases

 Encounter for chemotherapy

48

0.9

42

3

<.0001

 Mechanical complication of other vascular device, implant and graft

150

2.82

55

3.93

0.0390

Table 2

Univariate and multivariate analysis of comorbidity and morality in more than 65-year-old patients, N = 6729 (match 1:4)

Comorbidity

Crude Odds ratio

Adjusted Odds ratioa

OR

(95%CI)

OR

(95%CI)

Age(mean,sd)

1.026

1.018

1.035

1.024

1.015

1.034

Ischemic heart disease

 Acute myocardial infarction

4.067

2.883

5.737

4.503

3.060

6.627

 Hypertension

1.902

1.686

2.147

1.406

1.223

1.616

Heart failure

 Heart failure

2.732

2.209

3.38

1.800

1.404

2.309

 Cardiogenic shock

2.436

1.781

3.331

1.894

1.333

2.690

Vascular disease

 Arterial embolism and thrombosis of lower extremity

2.564

1.556

4.227

1.988

1.145

3.45

Respiratory disease

 Pneumonia, organism unspecified

1.965

1.615

2.39

1.448

1.14

1.838

 Empyema, without mention of fistula

2.643

1.128

6.197

3.272

1.307

8.194

Disease of GI system

 Gastric ulcer, chronic or unspecified with hemorrhage

1.856

1.506

2.288

1.381

1.079

1.768

 Acute vascular insufficiency of intestine

5.528

3.155

9.685

6.225

3.382

11.457

 Hemorrhage of gastrointestinal tract

3.264

2.331

4.572

1.868

1.259

2.772

 Duodenal ulcer, chronic or unspecified with perforation

2.239

1.724

2.908

2.209

1.637

2.982

 Peritonitis

8.559

3.889

18.838

8.855

3.653

21.47

 Perforation of intestine

2.423

1.599

3.67

2.636

1.67

4.162

Urinary disease

 Tuberculosis of ureter, tubercle bacilli found

3.6

2.421

5.353

3.699

2.347

5.831

 Chronic renal failure

3.183

2.565

3.95

2.931

2.241

3.834

 Calculus of ureter

0.442

0.295

0.661

0.588

0.376

0.919

 Hypertrophy (benign) of prostate

0.833

0.709

0.979

0.764

0.628

0.928

 Endocrine disease

0.512

0.445

0.588

0.668

0.568

0.785

Musculoskeletal disease

 Fracture of intertrochanteric section of femur, closed

1.607

1.321

1.954

1.284

1.023

1.613

Infectious disease

 Necrotizing fasciitis

1.74

1.203

2.517

1.580

1.041

2.397

CVA or trauma

 Subarachnoid hemorrhage

6.027

3.209

11.318

8.935

4.612

17.312

 Intracerebral hemorrhage

3.063

2.281

4.112

3.893

2.803

5.408

 Subdural hemorrhage

0.758

0.426

1.35

0.464

0.237

0.906

 Unspecified cerebral artery occlusion with cerebral infarction

1.788

1.477

2.165

1.512

1.216

1.881

 Other and unspecified cerebral laceration

2.553

1.353

4.819

3.058

1.513

6.178

 Subarachnoid hemorrhage following injury

2.591

1.955

3.434

4.12

3.014

5.632

 Fracture of vault of skull, closed

3.815

1.229

11.847

5.197

1.521

17.755

 Fracture of base of skull, closed

4.176

1.839

9.484

6.424

2.666

15.478

Cancer

 Malignant neoplasm of upper third of esophagus

2.87

1.207

6.824

3.624

1.394

9.422

 Malignant neoplasm of pyloric antrum of stomach

1.687

1.086

2.621

2.045

1.251

3.341

 Malignant neoplasm of liver, primary

2.828

1.9

4.208

2.944

1.826

4.745

 Malignant neoplasm of head of pancreas

3.109

1.492

6.478

4.035

1.809

9.002

 Malignant neoplasm of female breast, unspecifie

0.402

0.16

1.014

0.335

0.119

0.939

 Secondary malignant neoplasm of skin

3.705

2.133

6.436

3.418

1.796

6.506

Other diseases

 Encounter for chemotherapy

3.4

2.237

5.166

2.566

1.531

4.301

aAdjusted variables including age, gender, types of surgery, comorbidity

Table 3

Predictors of mortality in more than 65-year-old patients, N = 6729 (By stepwise)

Comorbidity

step

Adjusted Odds ratio

OR

(95%CI)

Chronic renal failure

1

2.806

2.205

3.571

Acute myocardial infarction

2

4.58

3.135

6.691

Intracerebral hemorrhage

3

3.758

2.724

5.184

Subarachnoid hemorrhage following injury

4

3.937

2.891

5.363

Tuberculosis of ureter, tubercle bacilli found

5

3.573

2.282

5.594

Heart failure

6

1.863

1.463

2.371

Subarachnoid hemorrhage

7

8.654

4.473

16.742

Duodenal ulcer, chronic or unspecified with perforation

8

2.262

1.688

3.033

Acute vascular insufficiency of intestine

9

6.406

3.503

11.716

Peritonitis

10

9.242

3.872

22.063

Endocrine disease

11

0.656

0.559

0.768

Age(mean,sd)

12

1.024

1.015

1.034

Malignant neoplasm of liver

13

3.193

2.042

4.992

Encounter for chemotherapy

14

2.739

1.667

4.501

Perforation of intestine

15

2.683

1.705

4.222

Cardiogenic shock

16

1.963

1.388

2.776

Fracture of base of skull, closed with subarchn

17

6.619

2.812

15.58

Sex(Male)

18

0.762

0.659

0.881

Unspecified cerebral artery occlusion with cerebral infarction

19

1.514

1.221

1.877

Hemorrhage of gastrointestinal tract

20

1.903

1.291

2.805

Secondary malignant neoplasm of skin

21

3.328

1.787

6.199

Malignant neoplasm of head of pancreas

22

3.89

1.753

8.633

Malignant neoplasm of pyloric antrum of stomach

23

2.035

1.253

3.304

Pneumonia, organism unspecified

24

1.397

1.115

1.751

Other and unspecified cerebral laceration

25

3.051

1.524

6.109

Hypertrophy (benign) of prostate

26

0.78

0.645

0.943

Gastric ulcer, chronic or unspecified with hemorrhage

27

1.403

1.103

1.784

Fracture of vault of skull, closed

28

4.976

1.451

17.06

Malignant neoplasm of upper third of esophagus

29

3.391

1.315

8.742

Empyema, without mention of fistula

30

3.22

1.297

7.997

Arterial embolism and thrombosis of lower extremity

31

1.952

1.122

3.394

Malignant neoplasm of female breast

32

0.31

0.11

0.868

Subdural hemorrhage

33

0.47

0.244

0.903

Gastric ulcer, chronic or unspecified with hemorrhage

34

1.403

1.103

1.784

Calculus of ureter

35

0.621

0.403

0.959

Necrotizing fasciitis

36

1.591

1.052

2.407

Fracture of intertrochanteric section of femur, closed

37

1.285

1.026

1.61

Discussion

With better medical quality and living condition, geriatric patient population is growing and often pose a significant challenge in surgery and anesthesia. Geriatric patients are relative fragile and also develop more complication after anesthesia than general population [1, 15]. The most common postoperative complication is pulmonary complication and the secondary is cardiac event, leading to longer hospitalization and increased mortality. In previous study in Taiwan, relationship between postoperative complications and mortality risk was established, but there was no analysis between preoperative comorbidities and post-operative mortality. The leading preoperative comorbidities were listed as following: Hypertension, Diabetes mellitus, Coronary artery disease, Pulmonary disease, Malignancy, Hepatic dysfunction, and Renal dysfunction. Detailed evaluation and better communicating the aforementioned risk factors to these patients before operation are suggested for improving anesthesia quality and surgical outcomes [16].

A comprehensive geriatric assessment including Activities of Daily Living (IADL), cognitive function, nutrition status, and past medical history were used to predict postoperative morbidity and mortality in geriatric patients who received elective surgery [17, 18]. They came to a conclusion that aging itself not increase surgical risk, rather, the increasing prevalence of chronic disease and the deterioration of the organ’s functions, might increase the risk of postoperative mortality. Geriatric patients tend to carry more than one comorbidity and it is a risk factor for functional decline, disability, dependency, and institutionalization. Risk of functional decline and deterioration of the organ’s functions following comorbidities rather than age itself play an more important role in geriatric patients surgical risk assessment.

In 2015, several large scale study concerning postoperative morbidity and mortality were published, including using multidimensional frailty score to predict postoperative complications in older female cancer patients [18], peer review reporting ASA classification as a reliable independent predictor of medical complications and mortality following surgery [7], a retrospective cohort study using national anesthesia clinical outcome registry [19] on perioperative mortality in 2010 to 2014, the effect of adding functional classification to ASA status for predicting 30-day mortality [20], and newly established preoperative score to predict postoperative mortality (POSPOM) [21]. All the above indicate that the lacking and desiring of an objective preoperative evaluation tool to predict perioperative risk and morbidity.

This is the first retrospective cohort study investigating relationship of comorbidity of elder patients with 30 day post-anesthetic mortality rate using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) from Taiwan Health Insurance database. We solely investigated disease code in our study to diminish other man-made bias in the health insurance database and aggregated them into 73 comorbidities by expertise to include most comorbidities. We also adopted death date to include both in-hospital and out-of-hospital death to avoid mortality bias. We used 1:4 propensity score matching case control to select comparable controls, but there were still significant differences in age and sex proportions (p < 0.001). A possible explanation is that the large sample size in the present study might be the reason for the statistical significance, but not clinically significant [22]. For example, the difference between 76 years old in non-death group and 78 years old in death group. Multivariate logistic model with stepwise variable selection was then applied to analysis the ability of comorbidities to predict postoperative mortality. From the 33 comorbidities, the leading comorbidity predicts post-anesthetic mortality in order is chronic renal failure, acute myocardial infarction, and intracerebral hemorrhage.

In the past, cardiovascular disease was regarded as the leading comorbidity that contribute to aged patients’ functional decline [23]. Due to poor cardiopulmonary reserve, limited daily activity and function capacity resulted in disability and institutionalization. However, chronic renal dysfunction was found to have better predicting ability to postoperative mortality than myocardia infarction by stepwise variable selection in our study. This can be explained by the increasing number of hemodialyzed patients in Taiwan after National Health Insurance put into practice. Due to low cost of insurance fee, patients with chronic renal failure received more medical care and have longer life span. However, multiple organ system deteriorated rapidly and thromboembolic events increased with longer duration of hemodialysis [24]. Amputation and artificial vascular surgery put these patients in a higher mortality rate after anesthesia [25]. Chronic kidney disease associated with increased risk of death, increased cardiovascular events and hospitalization was proven [26] and it also increased adverse outcome after elective orthopedic, general, and vascular surgery [27].

The secondary leading comorbidity predicting post-anesthetic mortality was acute myocardial infarction compatible as other studies. Risks related to the patient and related to surgery are both high for unstable hemodynamic status and emergent coronary artery bypass. A recent myocardial infarction remains a significant risk factor for postoperative MI and mortality and postponing elective operation after optimizing medical treatment is suggested [28]. Intracerebral hemorrhage was the tertiary leading comorbidity which is correlated with hemorrhagic stroke and traumatic injury accompany with poor outcome. Intracerebral hemorrhage is the most devastating type of stroke leading to greatest mortality and it is also an important public health problem leading to high rates of disability in geriatric patients [29]. Post-operative mortality is high in patients diagnosed as intracerebral hemorrhage undergoing blood evacuation.

In Current era of informative age, large scale of medical data was stored and established as a database in the national health insurance institute. From that, enormous amount of information can be acquired and work up. The limitation of our study is that our database is 1 million Longitudinal Health Insurance Database in 2005. The population is small and the data is old. The international classification of disease(ICD-9) had revised to 10th version and aggregation of ICD-9 codes made man-made bias. Besides, functional classification of ASA and geriatric dysfunction assessment were not included in the database of National Taiwan Health Insurance. Better registration system and further studies were warranted.

Conclusions

We design this study to present the leading comorbidity contributing to the postoperative mortality in elderly patients in Taiwan from Taiwan’s National Health Insurance Database. In our study, we diminish the impact of type of surgery, age, and sex by using matched propensity score and we use death date as the definition of mortality, which include in-hospital and out-of-hospital mortality. We concluded that chronic renal failure, acute myocardial infarction, and intracerebral hemorrhage are the leading comorbidity contribute to post-anesthetic mortality in geriatric patients in Taiwan. Our findings highlight the clinical importance of chronic renal failure in geriatric population.

Declarations

Acknowledgements

None to report.

Funding

None to report.

Availability of data and materials

The data that support the findings of this study are available from National Health Insurance Administration Ministry of Health and Welfare in Taiwan but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of National Health Insurance Administration Ministry of Health and Welfare in Taiwan.

Authors’ contributions

C.CL: writing the first draft, design the study. C.HY: critical revision for important intellectual content. C.WH: acquisition of data, data analysis. C.PY: data analysis. H.YY: supervision, critical revision. Y.HM: design the study, writing the first draft. All authors have read and approved the final manuscript.

Ethics approval and consent to participate

National Taiwan University Hospital Ethics Committee (201411078RINC) and inform consent was waived by the ethics committee.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Institute of Biomedical Engineering National Taiwan University
(2)
Department of Anesthesiology, National Taiwan University Hospital Yun-Lin Branch
(3)
School of Public Health, Taipei Medical University
(4)
Department of Anesthesiology, National Taiwan University Hospital

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Copyright

© The Author(s). 2017

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