Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample

Abstract

Background: Systematic screening and treatment of sleep-disordered breathing (SDB) or obstructive sleep apnea (OSA) in presurgical patients would impose a significant cost burden; therefore, it is important to understand whether SDB is associated with worse postoperative outcomes. We sought to determine the impact of SDB on postoperative outcomes in patients undergoing four specific categories of elective surgery (orthopedic, prostate, abdominal, and cardiovascular). The primary outcomes were in-hospital death, total charges, and length of stay (LOS). Two secondary outcomes of interest were respiratory and cardiac complications.

Methods: Data were obtained from the Nationwide Inpatient Sample database. Regression models were fitted to assess the independent association between SDB and the outcomes of interest.

Results: The cohort included 1,058,710 hospitalized adult patients undergoing elective surgeries between 2004 and 2008. SDB was independently associated with decreased mortality in the orthopedic (OR, 0.65; 95% CI, 0.45-0.95; P = .03), abdominal (OR, 0.38; 95% CI, 0.22-0.65; P = .001), and cardiovascular surgery groups (OR, 0.54; 95% CI, 0.40-0.73; P < .001) but had no impact on mortality in the prostate surgery group. SDB was independently associated with a small, but statistically significant increase in estimated mean LOS by 0.14 days (P < .001) and estimated mean total charges by $860 (P < .001) in the orthopedic surgery group but was not associated with increased LOS or total charges in the prostate surgery group. In the abdominal and cardiovascular surgery groups, SDB was associated with a significant decrease in adjusted mean LOS of 1.1 days and 0.35 days, respectively (P < .001 for both groups), and adjusted mean total charges of $3,814 and $4,592, respectively (P < .001 for both groups). SDB was independently associated with a significantly increased OR for emergent intubation and mechanical ventilation, noninvasive ventilation, and atrial fibrillation in all four surgical categories. Emergent intubation occurred significantly earlier in the postoperative course in patients with SDB. In the subgroup of patients requiring emergent intubation, LOS, total charges, pneumonias, and in-hospital death were significantly higher in those without SDB.

Conclusions: In this large national study, despite the increased independent association of SDB with postoperative cardiopulmonary complications, the diagnosis of SDB was not independently associated with an increased rate of in-hospital death. SDB had a mixed impact on LOS and total charges by surgical category.

Figure 1.

Prevalence of SDB in all surgical categories from 2004 to 2008. For each category, there was an increase in reporting SDB over the 5-year period. The year-to-year increase in SDB reporting was also significant in each surgical category (all P < .01). SDB = sleep-disordered breathing.

Figure 2.

Unadjusted outcomes for intubation, respiratory failure, CPAP/noninvasive ventilation use, and atrial fibrillation in patients with and without SDB. *P < .001; †P = .03. See Figure 1 legend for expansion of abbreviation.

Figure 3.

Mean adjusted length of stay and total charges in various surgical categories in patients with and without SDB. *P < .001. See Figure 1 legend for expansion of abbreviation.

Figure 4.

Mean adjusted length of stay and total charges in patients with and without SBD who required emergent endotracheal intubation. *P < .001. See Figure 1 legend for expansion of abbreviations.