Validation of the days alive and out of hospital outcome measure after emergency laparotomy: a retrospective cohort study

Days Alive Out of Health Care: A Novel Measure of Health Status After Congenital Heart Surgery

BACKGROUND

As pediatric and adult operative mortality improves, longitudinal outcomes beyond survival become increasingly important. "Days alive and out of hospital" is well-studied as a longitudinal, patient-centered outcome in adult populations. However, it has yet to be validated for children, whose health care use and survival differ from that of adults.

OBJECTIVES

This study sought to evaluate days alive and out of health care/hospital as outcomes for neonatal and infant cardiac surgery.

METHODS

Using linked, locally held, clinical registry data, the National Death Index, and Medicaid claims from the CHS-COLOUR (New York Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources), we describe and compare the distribution of days alive and out of health care/hospital (730 days or date of death minus date of birth, minus the sum of days in health care) over 2 years for New York State Medicaid-enrolled children who underwent initial neonatal or infant cardiac surgery during 2006 to 2018. We assess relative contributions of mortality, inpatient, and outpatient days, test impacts of alternate outpatient day weightings, and assess associations with patient characteristics known to be associated with other, established congenital heart surgical outcomes.

RESULTS

In total, 2,519 Medicaid-enrolled neonates/infants underwent initial cardiac surgery in the first year of life across New York state during 2006 to 2018. Days alive and out of health care (DAoH) (0-730 days) was bimodally distributed, with 10.4% (n = 261) spending <100 days and 21.6% (n = 545) spending >700 DAoH. We found that 5.9% (n = 149) of children died during their birth admission (0 DAoH). Cardiac disease complexity, weight at surgery, noncardiac preoperative comorbidities, and other preoperative risk factors were all significantly associated with the outcomes (P <0.001). When considering only inpatient days, the distribution was more left-skewed, because 40% of health care days in the second year of life was attributable to outpatient days. Our findings were otherwise largely insensitive to health care type weightings.

CONCLUSIONS

In this data set of children with Medicaid coverage, total DAoH is an easily reproducible, patient-centered outcome that should be considered for assessment of longitudinal outcomes for neonates and infants undergoing cardiac surgery. Where outpatient data are not available, days alive and out of hospital might serve as a reasonable alternative.

Advancing patient-centered metrics for heart transplantation: The role of days alive and outside the hospital

BACKGROUND

Heart transplantation (HT) survival and waitlist times are established outcome metrics. Patient-centered HT outcomes are insufficiently characterized. This study evaluates the role of days alive and outside the hospital (DAOH) as a candidate patient-centered HT performance measure.

METHODS

The study cohort included Medicare beneficiaries undergoing HT (July 2008-December 2017). The percent of days outside of hospital (%DOH) 6 months before (%DOH-BF) and percent of days alive outside of hospital 12 months after HT (%DAOH-AF) were evaluated along with adverse events (AEs, early: ≤3 months; late: 4-12 months). Patients were stratified by patient %DAOH-AF terciles. Risk-adjusted %DAOH was evaluated across hospitals.

RESULTS

A total of 5,104 beneficiaries underwent HT across 108 hospitals. Median [interquartile range (IQR)] age was 62 [53-67] years, 23.9% were female, and 21.4% were African-American. The overall median %DOAH-AF was 92.9% [83.8%, 95.9%], varying by tercile: low 71.8% [4.9%, 83.6%], intermediate 92.9% [91%, 94%]; high 96.4% [95.9%, 97.3%]. The lowest (vs highest) tercile %DAOH-AF had a lower median %DOH-BF (88% [73%-97%] vs 92% [81%-98%]) and longer post-HT inpatient stay (54 [36-81] vs 13 [10-15] days). After HT, the lowest versus highest tercile had greater AEs burden in the early (allograft failure [16.1% vs 1.6%], stroke [12.1% vs 2.3%]) and late (stroke [5.1% vs 1.9%], sternal wound infection [5.0% vs 0.8%]) phases post-HT. The mean hospital %DAOHadj was 80.5% (min:max 57.7%-96.7%).

CONCLUSIONS

Post-HT %DAOH varies across beneficiaries and hospitals and is associated with AEs. Further research is warranted to assess the role and validity of %DAOH as an HT quality metric.

A high rate of mortality in liver cirrhosis patients after emergency abdominal surgery

PURPOSE

In the elective setting, there are high mortality rates for patients with liver cirrhosis after surgery. Few studies focus on emergency surgery. This study investigates mortality and morbidity of patients with cirrhosis undergoing emergency abdominal surgery.

METHODS

In a database established at two Copenhagen University Hospitals (Herlev and North Zealand), including all patients operated in an emergency setting (n = 1116), including all patients with known cirrhosis at time of surgery. Postoperative complications, and mortality rates were evaluated by a matched case-control method, matching cases and controls according to surgical procedure, age, sex and American Society of Anaesthesiologists-class (ASA). Medical and surgical complications were classified according to the Clavien-Dindo classification.

RESULTS

In the study, 24 patients with cirrhosis and 48 matched controls were evaluated. The 30-day mortality was 37.5% for patients with cirrhosis and 12.5% for controls (OR 4.2, 95% CI [1.28, 13.80], p = 0.014) and 90-day mortality was 62.5% for patients with cirrhosis compared to 18.8% for controls (OR 7.22, 95% CI [2.41, 21.68], p < 0.001). For patients with cirrhosis 58.3% had surgical complications compared to 31.3% for the controls (p = 0.027). The reoperation rate was 45.8% in the cirrhosis group and 22.9% in the control group (p = 0.047). The days-alive-out-of-hospital at 90-days (DAOH-90) was 9 days in the cirrhosis group and 78 days in the control group (p < 0.001).

CONCLUSION

This retrospective study shows that patients with cirrhosis have significantly higher mortality rates after emergency surgery, more surgical complications and reoperations, and reduced DAOH-90.

Patient-centred outcome following endoscopic management of benign central airway obstruction

PURPOSE

To examine patient-centred outcome following endoscopic treatment of central airway stenosis in terms of days alive and out of hospital (DAOH), need for re-intervention, and complications, with reference to aetiology of disease and applied treatment methodology.

METHODS

Analyses were based on data from consecutive adult patients treated endoscopically for benign central airway obstruction at Aarhus University Hospital from 2012 to 2022, with a minimum follow-up of one year. DAOH was calculated for 30 and 365 days. Complications were graded based on the Clavien-Dindo classification. Univariate and multivariate analyses were performed to identify predictors for DAOH, re-intervention and complications.

RESULTS

82 consecutive adult patients underwent endoscopic treatment during the period of inclusion, comprising a total of 175 dilatations, 42 benign tumour resections, and 67 stent insertions. Multiple interventions and short re-intervention intervals was more likely amongst patients reporting significant preoperative dyspnoea or requiring preoperative respiratory support, as well as patients treated with endoscopic insertion of silicone stents. The overall complication rate per procedure was 11.7%, and complications were more likely to occur in patients with high age, high BMI and comorbidity. Overall DAOH during the first year after intervention was 343 days, lowest amongst patients with tracheobronchomalacia or severe airway stenosis, and in those who underwent endoscopic stent insertion.

CONCLUSION

Endoscopic treatment is a safe and viable intervention in the management of benign central airway obstruction in adults with few complications and a high overall outcome.

Differences in Postoperative Disposition by Kidney Disease Severity: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

People with advanced kidney disease undergo more non-cardiac operations compared to the general population, with a higher risk of perioperative cardiac events and death. However, little is known about the associations between severity of preoperative kidney dysfunction with postoperative length of hospitalization and discharge disposition; these were the focus of this study.

STUDY DESIGN

Population-based retrospective cohort.

SETTING & PARTICIPANTS

Adults from Alberta, Canada undergoing inpatient major noncardiac surgery between April 2005 and February 2019.

EXPOSURE

Categorical preoperative outpatient estimated glomerular filtration rate (eGFR) or kidney failure status.

OUTCOMES

Length of stay (LOS), days alive at home after surgery within 30 and 90 days, and discharge disposition location.

ANALYTICAL APPROACH

Associations were estimated with unadjusted and adjusted generalized estimating equation models.

RESULTS

927,560 inpatient surgeries in 666,770 people (55.9% female, median age 57.4 years) were identified. People receiving dialysis had the longest LOS (11 days [95% CI 6, 29), 2 times greater than that among people with normal kidney function (adjusted incidence rate ratio [IRR] 2.21 [95% CI 2.10, 2.32]). This group also had the fewest days alive at home within the first 30 days after surgery, with an IRR of 0.69 (95% CI 0.67, 0.70) compared to people with normal eGFR. The majority of people (82.8%) were discharged home without nursing support after surgery, though people receiving dialysis were discharged to a facility with 24-hour nursing care nearly 4 times more often. There were graded increases in risks of these outcomes with lower levels of kidney function.

LIMITATIONS

Many people did not have preoperative kidney function assessed, reflecting standard clinical practice in the general population.

CONCLUSIONS

After major surgery, people with kidney disease spend more time recovering in hospital and have less independence from post-discharge nursing supports than otherwise similar patients who have normal or near normal kidney function. These differences were more pronounced for those with the most severe stages of kidney disease.

Association between comprehensive geriatric assessment and Days Alive and Out of Hospital at 30 Days After Cardiac Surgery in Older Patients

OBJECTIVES

To investigate the association of comprehensive geriatric assessment (related to diverse aspects of frailty) with postoperative recovery as measured by days alive and out of the hospital at 30 days (DAOH30) in older patients undergoing cardiac surgery.

DESIGN

Retrospective observational study using data retrieved from a prospective registry.

SETTING

Single tertiary hospital in South Korea.

PARTICIPANTS

A total of 437 patients aged ≥65 years who underwent cardiac surgery between March 2021 and October 2022 were included.

MEASUREMENTS

Comprehensive geriatric assessment included subjective evaluations of functional frailty (cognitive, emotional, and physical aspects) and objective measurements of malnutrition and anaemia. DAOH30 was analysed using multivariable quantile regression to evaluate its association with these three domains.

RESULTS

In the entire cohort (median age 72 years; median DAOH30, 19 days), 85.1% of participants had functional frailty, 9.8% had malnutrition, and 45.8% had anaemia. Older age, cognitive dysfunction, emotional dysregulation, physical decline, malnutrition, and anaemia were associated with shorter DAOH30 (all p < 0.05). In multivariable analysis, malnutrition had the strongest impact, reducing DAOH30 by 6.0 days (95% confidence interval [CI]: -11.103 to -0.263), followed by anaemia (1.2 days, 95% CI: -2.199 to -0.148) and functional frailty (1.0 days, 95% CI: -1.677 to -0.171). Individual components of functional frailty did not retain an independently significant relationship with DAOH30 after adjustment for confounders.

CONCLUSION

Comprehensive geriatric assessment, incorporating functional frailty, malnutrition, and anaemia, demonstrated a significant association with DAOH30 in older patients undergoing cardiac surgery. Among the assessed aspects, malnutrition showed the strongest association, which may underscore the importance of targeted nutritional interventions to improve outcomes in this patient population.

Emergency laparotomy preoperative risk assessment tool performance: A systematic review

Background

Preoperative assessment of risk for emergency laparotomy may enhance decision making with regards to urgency or perioperative critical care admission and promote a more informed consent process for patients. Accordingly, we aimed to assess the performance of risk assessment tools in predicting mortality after emergency laparotomy.

Methods

PubMed, Embase, the Cochrane Library and CINAHL were searched to 12 February 2022 for observational studies reporting expected mortality based on a preoperative risk assessment and actual mortality after emergency laparotomy. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, expected and actual mortality rates were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42022299227.

Results

From 10,168 records, 82 observational studies were included. 17 risk assessment tools were described, the most common of which were P-POSSUM (42 studies), POSSUM (13 studies), NELA (12 studies) and MPI (11 studies). Articles were published between 1990 and 2022 with the most common country of origin being the UK (33 studies) followed by India (11 studies). Meta-analysis was not possible. Observed mortality and expected mortality based on risk assessment is reported for each study and generally shows most studies show accurate risk prediction.

Conclusions

This review synthesises available literature to characterise the performance of various risk assessment tools in predicting mortality after emergency laparotomy. Findings from this study may benefit those undertaking emergency laparotomy and future research in risk prediction.

Days at home after surgery as a perioperative outcome: scoping review and recommendations for use in health services research

BACKGROUND

Days at home after surgery is a promising new patient-centred outcome metric that measures time spent outside of healthcare institutions and mortality. The aim of this scoping review was to synthesize the use of days at home in perioperative research and evaluate how it has been termed, defined, and validated, with a view to inform future use.

METHODS

The search was run on MEDLINE, Embase, and Scopus on 30 March 2023 to capture all perioperative research where days at home or equivalent was measured. Days at home was defined as any outcome where time spent outside of hospitals and/or healthcare institutions was calculated.

RESULTS

A total of 78 articles were included. Days at home has been increasingly used, with most studies published in 2022 (35, 45%). Days at home has been applied in multiple study design types, with varying terminology applied. There is variability in how days at home has been defined, with variation in measures of healthcare utilization incorporated across studies. Poor reporting was noted, with 14 studies (18%) not defining how days at home was operationalized and 18 studies (23%) not reporting how death was handled. Construct and criterion validity were demonstrated across seven validation studies in different surgical populations.

CONCLUSION

Days at home after surgery is a robust, flexible, and validated outcome measure that is being increasingly used as a patient-centred metric after surgery. With growing use, there is also growing variability in terms used, definitions applied, and reporting standards. This review summarizes these findings to work towards coordinating and standardizing the use of days at home after surgery as a patient-centred policy and research tool.

An Approach for Combining Clinical Judgment with Machine Learning to Inform Medical Decision Making: Analysis of Nonemergency Surgery Strategies for Acute Appendicitis in Patients with Multiple Long-Term Conditions

BACKGROUND

Machine learning (ML) methods can identify complex patterns of treatment effect heterogeneity. However, before ML can help to personalize decision making, transparent approaches must be developed that draw on clinical judgment. We develop an approach that combines clinical judgment with ML to generate appropriate comparative effectiveness evidence for informing decision making.

METHODS

We motivate this approach in evaluating the effectiveness of nonemergency surgery (NES) strategies, such as antibiotic therapy, for people with acute appendicitis who have multiple long-term conditions (MLTCs) compared with emergency surgery (ES). Our 4-stage approach 1) draws on clinical judgment about which patient characteristics and morbidities modify the relative effectiveness of NES; 2) selects additional covariates from a high-dimensional covariate space (P > 500) by applying an ML approach, least absolute shrinkage and selection operator (LASSO), to large-scale administrative data (N = 24,312); 3) generates estimates of comparative effectiveness for relevant subgroups; and 4) presents evidence in a suitable form for decision making.

RESULTS

This approach provides useful evidence for clinically relevant subgroups. We found that overall NES strategies led to increases in the mean number of days alive and out-of-hospital compared with ES, but estimates differed across subgroups, ranging from 21.2 (95% confidence interval: 1.8 to 40.5) for patients with chronic heart failure and chronic kidney disease to -10.4 (-29.8 to 9.1) for patients with cancer and hypertension. Our interactive tool for visualizing ML output allows for findings to be customized according to the specific needs of the clinical decision maker.

CONCLUSIONS

This principled approach of combining clinical judgment with an ML approach can improve trust, relevance, and usefulness of the evidence generated for clinical decision making.

HIGHLIGHTS

Machine learning (ML) methods have many potential applications in medical decision making, but the lack of model interpretability and usability constitutes an important barrier for the wider adoption of ML evidence in practice.We develop a 4-stage approach for integrating clinical judgment into the way an ML approach is used to estimate and report comparative effectiveness.We illustrate the approach in undertaking an evaluation of nonemergency surgery (NES) strategies for acute appendicitis in patients with multiple long-term conditions and find that NES strategies lead to better outcomes compared with emergency surgery and that the effects differ across subgroups.We develop an interactive tool for visualizing the results of this study that allows findings to be customized according to the user's preferences.

Impact of Perioperative Pulmonary Artery Catheter Use on Clinical Outcomes After Cardiac Surgery: A Nationwide Cohort Study

BACKGROUND

Evidence on the effectiveness of pulmonary artery catheters (PACs) in cardiac surgery is scarce.

RESEARCH QUESTION

Does perioperative PAC use decrease 1-year all-cause mortality in patients undergoing cardiac surgery?

STUDY DESIGN AND METHODS

This nationwide, population-based cohort study included all adult patients who underwent cardiac surgery in Korea between January 2011 and December 2020 using a Korean health insurance claim database. We compared the primary outcome, the risk of 1-year all-cause mortality, between patients with and without perioperative use of PACs (PAC and no-PAC groups, respectively) using logistic regression analysis after stabilized inverse probability of treatment weighting. A subgroup analysis was performed to determine whether the association varied according to the type of cardiac surgery and institutional case volume.

RESULTS

A total of 61,405 patients were analyzed. The PAC group had a significantly lower risk of 1-year all-cause mortality than that in the no-PAC group (adjusted OR, 0.81; 95% CI, 0.76-0.86). In the subgroup analysis, both the type of cardiac surgery and institutional case volume were identified as significant modifiers (all P for interaction < .001). Specifically, the PAC group had a significantly lower risk of 1-year all-cause mortality after isolated off-pump coronary artery bypass grafting (adjusted OR, 0.54; 95% CI, 0.48-0.61) compared with the no-PAC group. PAC use was associated with a significant reduction in the risk of 1-year all-cause mortality in the lowest-case volume centers (< 100 cases/y; OR, 0.70; 95% CI, 0.65-0.76).

INTERPRETATION

Perioperative use of PACs was associated with a significant reduction in the risk of postoperative 1-year all-cause mortality. This association was driven predominantly by patients who underwent off-pump coronary artery bypass grafting and those who underwent cardiac surgery in less experienced centers.

The Cost-Effectiveness of Early High-Acuity Postoperative Care for Medium-Risk Surgical Patients

BACKGROUND

Initiatives in perioperative care warrant robust cost-effectiveness analysis in a cost-constrained era when high-value care is a priority. A model of anesthesia-led early high-acuity postoperative care, advanced recovery room care (ARRC), has shown benefit in terms of hospital and patient outcomes, but its cost-effectiveness has not yet been formally determined.

METHODS

Data from a previously published single-center prospective cohort study of ARRC in medium-risk patients were used to generate a Markov model, which described patient transition between care locations, each with different characteristics and costs. The incremental cost-effectiveness ratio (ICER), using days at home (DAH) and hospital costs, was calculated for ARRC compared to usual ward care using deterministic and probabilistic sensitivity analysis.

RESULTS

The Markov model accurately described patient disposition after surgery. For each patient, ARRC provided 4.3 more DAH within the first 90 days after surgery and decreased overall hospital costs by $1081 per patient. Probabilistic sensitivity analysis revealed that ARRC had a 99.3% probability of increased DAH and a 77.4% probability that ARRC was dominant from the perspective of the hospital, with improved outcomes and decreased costs.

CONCLUSIONS

Early high-acuity care for approximately 24 hours after surgery in medium-risk patients provides highly cost-effective improvements in outcomes when compared to usual ward care.

Health-related quality of life is a predictor of readmission following emergency laparotomy

BACKGROUND

Health-related quality of life (HRQoL) is a multidimensional concept used to examine the impact of patient-perceived health status on quality of life. Patients' perception of illness affects outcomes in both medical and elective surgical patients; however, not much is known about how HRQoL effects outcomes in the emergency surgical setting. This study aimed to examine if patient-reported HRQoL was a predictor of unplanned readmission after emergency laparotomy.

METHODS

This study included 215 patients who underwent emergency laparotomy at the Copenhagen University Hospital, Herlev, between August 1, 2021, and July 31, 2022. Patient-reported HRQoL was assessed with the EuroQol group EQ5D index (EQ5D5L descriptive system and EQ-VAS). The population was followed from 0 to 180 days after discharge, and readmissions and days alive and out of hospital were registered. A Cox proportional hazard model was used to examine HRQoL and the risk of readmission within 30 and 180 days.

RESULTS

Within 30 days, 28.4% of patients were readmitted; within 180 days, the number accumulated to 45.1%. Low self-evaluated HRQoL predicted 180-day readmission and was significantly associated with fewer days out of hospital within both 90 and 180 days. Low HRQoL and discharge with rehabilitation were independent risk factors for short- (30-day) and long-term (180-day) emergency readmission.

CONCLUSION

Patient-perceived quality of life is an independent predictor of 180-day readmission, and the number of days out of hospital was correlated to self-reported HRQoL.

Disparities in prehospital and emergency surgical care among patients with perforated ulcers and a history of mental illness: a nationwide cohort study

PURPOSE

To compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer.

METHODS

A nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016-2017 and the Danish Emergency Surgery Registry 2004-2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history.

RESULTS

We identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up.

CONCLUSION

One-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality.

Influence of acute kidney injury and its recovery subtypes on patient-centered outcomes after lung transplantation

This study aimed to investigate the association between acute kidney injury (AKI) recovery subtypes and days alive out of hospital within the first 3 months (DAOH-90) in patients undergoing lung transplantation. Patients who underwent lung transplantation from January 2012 to December 2021 were retrospectively analyzed and stratified into three groups: no-AKI, early recovery AKI (within 7 days), and non-early recovery AKI group. AKI occurred in 86 (35%) of patients, of which 40 (16%) achieved early recovery, and the remaining 46 (19%) did not. The median DAOH-90 was 21 days shorter in the AKI than in the no-AKI (P = 0.002), and 29 days shorter in the non-early recovery AKI group than in the no-AKI group (P < 0.001). Non-early recovery AKI and preoperative tracheostomy status were independently associated with shorter DAOH-90. The prevalence of CKD (76%), and 1-year mortality (48%) were highest in the non-early recovery AKI group. Postoperative AKI was associated with an adverse patient-centered quality measure for perioperative care, and shorter DAOH-90. The non-early recovery AKI group exhibited the worst prognosis in terms of DAOH-90, CKD progression, and 1-year mortality, highlighting the important role of AKI and early-recovery AKI on both the quality of life and clinical outcomes after lung transplantation.

PHYSIO+++: protocol for a pilot randomised controlled trial assessing the feasibility of physiotherapist-led non-invasive ventilation for patients with hypoxaemia following abdominal surgery

INTRODUCTION

Few clinical trials have investigated physiotherapy interventions to treat hypoxaemia following abdominal surgery. The objective of this study is to determine the feasibility and safety of conducting a clinical trial of physiotherapist-led non-invasive ventilation (NIV).

METHODS AND ANALYSIS

This single-centre, 50-patient, parallel-group, assessor blinded, pilot feasibility randomised controlled trial with concealed allocation will enrol spontaneously ventilating adults with hypoxaemia within 72 hours of major abdominal surgery. Participants will receive either (1) usual care physiotherapy of a single education session (talk), daily walking of 10-15 min (walk) and four sessions of coached deep breathing and coughing (breathe) or (2) usual care physiotherapy plus four 30 min sessions of physiotherapist-led NIV delivered over 2 postoperative days. Primary feasibility and safety outcome measures are; number of eligible patients recruited per week, total time of NIV treatment delivered, acceptability of treatments to patients and clinicians and incidence of adverse events. Secondary feasibility outcomes include measures of recruitment and treatment adherence. Exploratory outcome measures include change in respiratory parameters, postoperative pulmonary complications, length of hospital stay, health-related quality of life, postoperative activity levels and mortality.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the relevant institution. Results will be published to inform future research.

TRIAL REGISTRATION NUMBER

ACTRN12622000839707.

Composite quality measures of abdominal surgery at a population level: systematic review

BACKGROUND

Measurement of surgical quality at a population level is challenging. Composite quality measures derived from administrative and clinical information systems could support system-wide surgical quality improvement by providing a simple metric that can be evaluated over time. The aim of this systematic review was to identify published studies of composite measures used to assess the overall quality of abdominal surgical services at a hospital or population level.

METHODS

A search was conducted in PubMed and MEDLINE for references describing measurement instruments evaluating the overall quality of abdominal surgery. Instruments combining multiple process and quality indicators into a single composite quality score were included. The identified instruments were described in terms of transparency, justification, handling of missing data, case-mix adjustment, scale branding and choice of weight and uncertainty to assess their relative strengths and weaknesses (PROSPERO registration: CRD42022345074).

RESULTS

Of 5234 manuscripts screened, 13 were included. Ten unique composite quality measures were identified, mostly developed within the past decade. Outcome measures such as mortality rate (40 per cent), length of stay (40 per cent), complication rate (60 per cent) and morbidity rate (70 per cent) were consistently included. A major challenge for all instruments is the reliance of valid administrative data and the challenges of assigning appropriate weights to the underlying instrument components. A conceptual framework for composite measures of surgical quality was developed.

CONCLUSION

None of the composite quality measures identified demonstrated marked superiority over others. The degree to which administrative and clinical data influences each composite measure differs in important ways. There is a need for further testing and development of these measures.

Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit

BACKGROUND

Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database.

METHODS

A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori.

RESULTS

Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85).

CONCLUSIONS

Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.

Predictive Value of the Changes in Neutrophil-Lymphocyte Ratio for Outcomes After Off-Pump Coronary Surgery

Purpose

The neutrophil-to-lymphocyte ratio (NLR) is an extensively analyzed prognostic inflammatory index in cardiac patients. The degree of change in NLR values before and after surgery (delta-NLR) can represent the inflammatory response induced by surgery and serve as a meaningful prognostic biomarker in surgical patients; however, this has not been well investigated. We aimed to investigate the predictive value of the perioperative NLR and delta-NLR for outcomes of off-pump coronary artery bypass (OPCAB) surgery by evaluating "days alive and out of hospital (DAOH)", a novel patient-centered outcome.

Patients and Methods

In this single-center retrospective study, perioperative data, including NLR data, from 1322 patients were analyzed. The primary endpoint was DOAH at 90 days postoperatively (DAOH 90), and the secondary endpoint was long-term mortality. Linear regression analysis and Cox regression analysis were performed to identify independent risk factors for the endpoints. In addition, Kaplan-Meier survival curves were plotted to assess long-term mortality.

Results

The median NLR values significantly increased from 2.2 (1.6-3.1) at baseline to 7.4 (5.4-10.3) postoperatively, with median delta-NLR values of 5.0 (3.2-7.6). Preoperative NLR and delta-NLR were independent risk factors for short DAOH 90 in the linear regression analysis. In Cox regression analysis, delta-NLR, but not preoperative NLR, was an independent risk factor for long-term mortality. When patients were divided into two groups according to delta-NLR, the high delta-NLR group had a shorter DAOH 90 than the low delta-NLR group. Kaplan-Meier curves showed higher long-term mortality in the high delta-NLR group than in the low delta-NLR group.

Conclusion

In OPCAB patients, preoperative NLR and delta-NLR were significantly associated with DAOH 90, and delta-NLR was an independent risk factor for long-term mortality, indicating their role in risk assessment, which is essential for perioperative management.

Days Alive and Out of Hospital at 15 Days after Hip Replacement May Be Associated with Long-Term Mortality: Observational Cohort Study

We aimed to evaluate the association between days alive and out of hospital (DAOH) and mortality at 15 days after a hip replacement. From March 2010 to June 2020, we identified 5369 consecutive adult patients undergoing hip replacements and estimated DAOH at 15, 30, 60, and 90 days after surgery. After excluding 13 patients who died within 15 days after surgery, receiver operating characteristic (ROC) curves were then generated to evaluate predictabilities for each follow-up period. We compared the mortality risk according to the estimated thresholds of DAOH at 15 days after hip replacement. ROC analysis revealed areas under the curve of 0.862, 0.877, 0.906, and 0.922 for DAOH at 15, 30, 60, and 90 days after surgery, respectively. The estimated threshold of DAOH during the 15 postoperative days was 6.5. Patients were divided according to this threshold, and propensity score matching was conducted. In a propensity score-matched population with 864 patients in each group, the risk of mortality increased in patients with a lower DAOH 15 (2.8% vs. 8.1%; hazard ratio [HR] = 3.96; 95% confidence interval [CI]: 2.24–6.99; p < 0.001 for one-year mortality, 5.2% vs. 13.0%; HR = 3.82; 95% CI: 2.33–6.28; p < 0.001 for three-year mortality, and 5.9% vs. 15.6%; HR = 3.07; 95% CI: 2.04–4.61; p < 0.001 for five-year mortality). In patients undergoing a hip replacement, DAOH at 15 days after surgery was shown to be associated with increased mortality. DAOH at 15 days may be used as a valid outcome measure for hip replacement.

Days alive and out of hospital at 30 days and outcomes of off-pump coronary artery bypass grafting

Days alive and out of hospital (DAOH) is a simple estimator based on the number of days not in hospital within a defined period. In cases of mortality within the period, DAOH is regarded as zero. It has not been validated solely in off-pump coronary artery bypass grafting (OPCAB). This study aimed to demonstrate a correlation between DAOH and outcome of OPCAB. We identified 2211 OPCAB performed from January 2010 to August 2016. We calculated DAOH at 30 and 60 days. We generated a receiver-operating curve and compared outcomes. The median duration of hospital stay after OPCAB was 6 days. The median DAOH values at 30 and 60 days were 24 and 54 days. The estimated thresholds for 3-year mortality for DAOH at 30 and 60 days were 20 and 50 days. Three-year mortality was higher for short DAOH (1.2% vs. 5.7% and 1.1% vs. 5.6% DAOH at 30 and 60 days). After adjustment, the short DAOH 30 group showed significantly higher mortality during 3-year follow-up (hazard ratio 3.07; 95% confidence interval 1.45-6.52; p = 0.004). DAOH at 30 days after OPCAB showed a correlation with 3-year outcomes. DAOH 30 might be a reliable long-term outcome measure that can be obtained within 30 days after surgery.

Clinical effectiveness and cost-effectiveness of emergency surgery for adult emergency hospital admissions with common acute gastrointestinal conditions: the ESORT study

Background

Evidence is required on the clinical effectiveness and cost-effectiveness of emergency surgery compared with non-emergency surgery strategies (including medical management, non-surgical procedures and elective surgery) for patients admitted to hospital with common acute gastrointestinal conditions.

Objectives

We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups.

Methods

The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergency surgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year.

Results

Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery.

Limitations

The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers.

Conclusions

Neither strategy was more cost-effective overall. For patients with severe frailty, non-emergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective.

Future work

For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery.

Study registration

This study is registered as reviewregistry784.

Funding

This project was funded by the National Institute for Health and Care Research (IHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study

BACKGROUND

Frailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery.

METHODS

A retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed.

RESULTS

We identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60-0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64-0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month.

CONCLUSIONS

In patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.

An evaluation of the outcome metric 'days alive and at home' in older patients after hip fracture surgery

'Days alive and at home' is a validated measure that estimates the time spent at home, defined as the place of residence before admission to hospital. We evaluated this metric in older adults after hip fracture surgery and assessed two follow-up durations, 30 and 90 days. Patients aged ≥ 70 years who underwent hip fracture surgery were identified retrospectively via hospital admission and government mortality records. Patients who successfully returned home and were still alive within 90 days of surgery were distinguished from those who were not. Regression models were used to examine which variables were associated with failure to return home and number of days at home among those who did return, within 90 days of surgery. We analysed the records of 825 patients. Median (IQR [range]) number of days at home within 90 days (n = 788) was 54 (0-76 [0-88]) days and within 30 days (n = 797) it was 2 (0-21 [0-28]) days. Out of these, 274 (35%) patients did not return home within 90 days and 374 (47%) within 30 days after surgery. Known peri-operative risk-factors such as older age, pre-operative anaemia and postoperative acute renal impairment were associated with failure to return home. This study supports days alive and at home as a useful patient-centred outcome measure in older adults after hip fracture surgery. We recommend that this metric should be used in clinical trials and measured at 90, rather than 30, postoperative days. As nearly half of this patient population did not return home within 30 days, the shorter time-period catches fewer meaningful events.

Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database

The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: -0.73 days (-2.10-0.64) for appendicitis; 0.60 (-0.10-1.30) for gallstone disease; -2.66 (-15.7-10.4) for diverticular disease; -0.07 (-2.40-2.25) for hernia; and 3.32 (-3.13-9.76) for intestinal obstruction. For patients with 'severe frailty', mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: -21.0 (-27.4 to -14.6) for appendicitis; -5.72 (-11.3 to -0.2) for gallstone disease, -38.9 (-63.3 to -14.6) for diverticular disease; -19.5 (-26.6 to -12.3) for hernia; and - 34.5 (-46.7 to -22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: -0.18 (-1.56-1.20) for appendicitis; 0.93 (0.48-1.39) for gallstone disease; 5.35 (-2.56-13.28) for diverticular disease; 2.26 (0.37-4.15) for hernia; and 18.2 (14.8-22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.