title: Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators.
abstract: OBJECTIVE
  Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized.
  
  
  OBJECTIVE
  To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals.
  
  
  METHODS
  Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level.
  
  
  METHODS
  All-cause 30-day postoperative mortality.
  
  
  RESULTS
  The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/μL or more, 16.3% with 50/μL to 199/μL, and 3.7% with less than 50/μL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/μL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/μL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/μL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/μL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality.
  
  
  CONCLUSIONS
  Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.
authors.affiliation: Section of Neurosurgery, Department of Surgery, Veterans Affairs (VA) Connecticut Healthcare System, West Haven2Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Joseph T
authors.initials: JT
authors.lastname: King
authors.affiliation: Section of General Surgery, Department of Surgery, VA Connecticut Healthcare System, West Haven4Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Melissa F
authors.initials: MF
authors.lastname: Perkal
authors.affiliation: Section of General Surgery, Department of Surgery, VA Connecticut Healthcare System, West Haven4Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Ronnie A
authors.initials: RA
authors.lastname: Rosenthal
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania6Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania7Division of Infectious Diseases, Department of Medicine, University of Pittsbur.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Gordon
authors.affiliation: Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes, Rutgers University, New Brunswick, New Jersey.
authors.forename: Stephen
authors.initials: S
authors.lastname: Crystal
authors.affiliation: Section of Infectious Diseases, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas10Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Rodriguez-Barradas
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania6Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania7Division of Infectious Diseases, Department of Medicine, University of Pittsbur.
authors.forename: Adeel A
authors.initials: AA
authors.lastname: Butt
authors.affiliation: Section of Infectious Diseases, Medical Service, VA Medical Center, Washington, DC12Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Gibert
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Atlanta VA Medical Center, Atlanta, Georgia14Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: David
authors.initials: D
authors.lastname: Rimland
authors.affiliation: Section of Infectious Diseases, Department of Medicine, VA New York Harbor Healthcare System, New York, New York16Section of Infectious Diseases, Department of Medicine, New York University School of Medicine, New York.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Simberkoff
authors.affiliation: Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven18Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Amy C
authors.initials: AC
authors.lastname: Justice
mesh_terms: D000418:Albumins / Q000032:analysis; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006454:Hemoglobins / Q000032:analysis; D017052:Hospital Mortality; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D012367:RNA, Viral / Q000032:analysis; D013514:Surgical Procedures, Operative / Q000401:mortality*; D014481:United States / Q000453:epidemiology
chemical_list: D000418:Albumins; D019380:Anti-HIV Agents; D006454:Hemoglobins; D012367:RNA, Viral