Comparative Outcomes for Pelvic Organ Prolapse Surgery among Nursing Home Residents and Matched Community Dwelling Older Adults

Sacral neuromodulation in nursing home residents: Predictors of success and complications in a national cohort of older adults

AIMS

There is limited evidence to support the efficacy of sacral neuromodulation (SNM) for older adults with overactive bladder (OAB). This study aims to report outcomes following SNM among nursing home (NH) residents, a vulnerable population with high rates of frailty and comorbidity.

METHODS

This is a retrospective cohort study of long-stay NH residents who underwent a trial of percutaneous nerve evaluation (PNE) or Stage 1 permanent lead placement (Stage 1) between 2014 and 2016. Residents were identified using the Minimum Data Set linked to Medicare claims. The primary outcome of this study was successful progression from trial to implant. Rates of 1-year device explant/revisions were also investigated.

RESULTS

Trial of SNM was observed in 1089 residents (mean age: 77.9 years). PNE was performed in 66.9% of residents and 33.2% underwent Stage 1. Of Stage 1 procedures, 23.8% were performed with simultaneous device implant (single-stage). Overall, 53.1% of PNEs and 72.4% of Stage 1 progressed to device implant, which was associated with Stage 1 procedure versus PNE (adjusted relative risk [aRR]: 1.34; 95% confidence interval [95% CI]: 1.21-1.49) and female versus male sex (aRR: 1.26; 95% CI: 1.09-1.46). One-year explant/revision was observed in 9.3% of residents (6.3% for PNE, 10.5% for Stage 1, 20.3% single-stage). Single stage procedure versus PNE was significantly associated with device explant/revision (aRR: 3.4; 95% CI: 1.9-6.2).

CONCLUSIONS

In this large cohort of NH residents, outcomes following SNM were similar to previous reports of younger healthier cohorts. Surgeons managing older patients with OAB should use caution when selecting patients for single stage SNM procedures.

High risk of complications after a "low risk" procedure: A national study of nursing home residents and older adults undergoing haemorrhoid surgery

AIM

To evaluate 30-day complications and 1-year mortality for older adults undergoing haemorrhoid surgery.

METHOD

This retrospective cohort study evaluated older adults (age 66+) undergoing haemorrhoid surgery using Medicare claims and the minimum data set (MDS). Long-stay nursing home residents were identified, and propensity score matched to community-dwelling older adults. Generalized estimating equation models were created to determine the adjusted relative risk of 30-day complications, length of stay (LOS), and 1-year mortality. Among nursing home residents, functional and cognitive status were evaluated using the MDS-activities of daily living (ADL) score and the Brief Instrument of Mental Status. Faecal continence status was evaluated among a subset of nursing home residents.

RESULTS

A total of 3664 subjects underwent haemorrhoid surgery and were included in the analyses. Nursing home residents were at significantly higher risk for 30-day complications (52.3% vs. 32.9%, aRR 1.6 [95% CI: 1.5-1.7], p < 0.001), and 1-year mortality (24.9% vs. 16.1%, aRR 1.6 [95% CI: 1.3-1.8], p < 0.001). Functional and mental status showed an inflection point of decline around the time of the procedure, which did not recover to the baseline trajectory in the following year. Additionally, a subset of nursing home residents demonstrated worsening faecal incontinence.

CONCLUSION

This study demonstrated high rates of 30-day complications and 1-year mortality among all older adults (yet significantly worse among nursing home residents). Ultimately, primary care providers and surgeons should carefully weigh the potential harms of haemorrhoid surgery in older adults living in a nursing home.

The Role of Frailty on Surgical Outcomes Following Pelvic Organ Prolapse Surgery in Medicare Beneficiaries: A National Study

OBJECTIVE

To evaluate the association of frailty with surgical outcomes following pelvic organ prolapse (POP) surgery in Medicare beneficiaries.

METHODS

This is a retrospective cohort study of female Medicare beneficiaries ≥65 years of age undergoing POP surgery between 2014 and 2016. Primary outcomes were hospital length-of-stay (LOS) ≥3 days, 30-day post-operative complications (excluding urinary tract infections (UTI)), and 30-day UTI. Frailty was quantified using the validated Claims-Based Frailty Index (CFI) and categorized into not frail (CFI<0.15), pre-frail (0.15≤CFI<0.25), mildly frail (0.25≤CFI<0.35), and moderately to severely frail (0.35≤CFI≤1).

RESULTS

Among the 107,890 women included (mean age, 73.3±6 years), 91.3% were White as and 4.3% were classified as mildly or moderately to severely frail. Rates of hospital LOS≥3 days and 30-day UTI increased over 7-fold and rates of 30-day complications increased over 3-fold as CFI increased from not frail to moderately to severely frail (all P values <.001). Compared to women who were not frail, women who were moderately to severely frail demonstrated an increased relative risk of hospital LOS≥3 days (aRR 3.1 [95% CI 2.5-3.8,P <.001]), 30-day complications (aRR 2.8 [95% CI 2.2-3.6, P <.001]), and 30-day UTI (aRR 2.5 [95% CI 2.2-3.0, P <.001]).

CONCLUSION

Among Medicare beneficiaries undergoing POP surgery in the United States, frailty is strongly associated with increased risk of prolonged hospital stay and 30-day complications. Frailty should be considered in the preoperative assessment for POP surgeries to improve patient outcomes.

Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study

BACKGROUND

Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement.

METHODS

We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models.

RESULTS

From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores.

CONCLUSIONS

Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.

Frailty Is Associated with an Increased Risk of Complications and Need for Repeat Procedures after Sling Surgery in Older Adults

PURPOSE

Sling surgery is the gold standard treatment for stress urinary incontinence in women. While data support the use of sling surgery in younger and middle-aged women, outcomes in older, frail women are largely unknown.

MATERIALS AND METHODS

Data were examined for all Medicare beneficiaries ≥65 years old who underwent sling surgery with or without concomitant prolapse repair from 2014 to 2016. Beneficiaries were stratified using the Claims-Based Frailty Index (CFI) into 4 categories: not frail (CFI <0.15), prefrail (0.15 ≤CFI <0.25), mildly frail (0.25 ≤CFI <0.35) and moderately to severely frail (CFI ≥0.35). Outcomes included rates and relative risk of 30-day complications, 1-year mortality and repeat procedures for persistent incontinence or obstructed voiding at 1 year.

RESULTS

A total of 54,112 women underwent sling surgery during the study period, 5.2% of whom were mildly to moderately to severely frail. Compared to the not frail group, moderately to severely frail beneficiaries demonstrated an increased adjusted relative risk (aRR) of 30-day complications (56.5%; aRR 2.5, 95% CI: 2.2-2.9) and 1-year mortality (10.5%; aRR 6.7, 95% CI: 4.0-11.2). Additionally, there were higher rates of repeat procedures in mildly to severely frail beneficiaries (6.6%; aRR 1.4, 95% CI: 1.2-1.6) compared to beneficiaries who were not frail.

CONCLUSIONS

As frailty increased, there was an increased relative risk of 30-day complications, 1-year mortality and need for repeat procedures for persistent incontinence or obstructed voiding at 1 year. While there were fewer sling surgeries in performed frail women, the observed increase in complication rates was significant. Frailty should be strongly considered before pursuing sling surgery in older women.

Effect of Intelligent Medical Management Platform Combined with Perioperative Detailed Nursing on Cognitive Ability, Postoperative Complications, and Quality of Life of Patients Undergoing Hysterectomy

Objective. To analyze the effect of an intelligent medical management platform combined with perioperative detailed nursing on cognitive ability, postoperative complications, and quality of life (QOL) of patients undergoing hysterectomy. Methods. The clinical data of 76 patients undergoing hysterectomy in our hospital from December 2019 to December 2021 were selected for the retrospective analysis, and the patients were divided into the experimental group (EG, $n=38$ , intelligent medical management platform+perioperative detailed nursing) and the routine group (RG, $n=38$ , routine nursing) according to their admission order, and the cognition of disease and QOL after intervention of patients in the two groups were evaluated by the self-proposed questionnaire on cognition of disease of our hospital and the MOS 36-item short-form health survey (SF-36). Results. After intervention, the scores on cognitive ability, various nursing items, and QOL were significantly higher in EG than in RG ( $P<0.001$ ), and during the study, the total incidence rate of complications was significantly lower in EG than in RG ( $P<0.05$ ). Conclusion. Combining an intelligent medical management platform with perioperative detailed nursing is a reliable method to improve QOL and reduce postoperative complications for patients undergoing hysterectomy. Further research will be conducive to providing a reliable perioperative intervention scheme for such patients.

Comparative outcomes for older adults undergoing surgery for bladder and bowel dysfunction

BACKGROUND/OBJECTIVES

To compare surgical outcomes between vulnerable nursing home (NH) residents and matched community-dwelling older adults undergoing surgery for bladder and bowel dysfunction.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 55,389 NH residents and propensity matched (based on procedure, age, sex, race, comorbidity, and year) community-dwelling older adults undergoing surgery for bladder and bowel dysfunction [female pelvic surgery, transurethral resection of the prostate, suprapubic tube placement, hemorrhoid surgery, rectal prolapse surgery]. Individuals were identified using Medicare claims and the Minimum Data Set (MDS) for NH residents between 2014 and 2016.

MEASUREMENTS

Thirty-day complications, 1-year mortality, and weighted changes in healthcare resource utilization (hospital admissions, emergency room visits, office visits) in the year before and after surgery.

RESULTS

NH residents demonstrated statistically significant increased risk of 30-day complications [60.1% v. 47.2%; RR 1.3 (95% CI 1.3-1.3)] and 1-year mortality [28.9% vs. 21.3%; RR 1.4 (95% CI 1.3-1.4)], compared to community-dwelling older adults. NH residents also demonstrated decreased healthcare resource utilization, compared to community-dwelling older adults, changing from 3.9 to 1.9 (vs.1.1 to 1.0) hospital admissions, 11 to 10.1 (vs. 9 to 9.7) office visits, and 3.4 to 2.2 (vs. 1.9 to 1.9) emergency room visits from the year before to after surgery.

CONCLUSION

Despite matching on several important clinical characteristics, NH residents demonstrated increased rates of 30-day complications and 1-year mortality after surgery for bowel and bladder dysfunction, while demonstrating decreased healthcare resource utilization. These mixed findings suggest that outcomes may be more varied among vulnerable older adults and warrant further investigation.