The Significance of Discharge to Skilled Care After Abdominopelvic Surgery in Older Adults

The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection

BACKGROUND

Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined.

STUDY DESIGN

This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65-74, 75-84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility.

RESULTS

577 patients were included: 62.6 % were 65-74 years old, 31.7 % 75-84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility.

CONCLUSION

Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Preoperative Risk Factors for Discharge to Facility After Surgery in Geriatric Patients

BACKGROUND

The Geriatric Surgery Verification Program (GSV) was developed to address perioperative care for patients ≥75 years, with a goal of improving outcomes and functional abilities after surgery. We sought to evaluate preoperative factors that place patients at risk for inability to return home (ie, discharge to a facility).

METHODS

Retrospective review of patients ≥75 years old who underwent inpatient surgery from January 2018 to December 2022 at a referral Veterans Administration Medical Center enrolled in the GSV program. Preoperative factors included fall history, mobility aids, housing status, function, cognition, and nutritional status. Postoperative outcomes were discharge designations as home and home with services compared to a facility (skilled nursing facility and acute rehab). Exclusion criteria included preoperative facility residence, cardiac surgery, hospital transfer, postoperative complications, hospice discharge, or in-hospital mortality.

RESULTS

605 patients met inclusion criteria and 173 (29%) excluded as above. Of the remaining 432 patients, mean age was 79 ± 5 and the majority were male, 426 (99%). The majority of patients were discharged home, 388 (90%), compared to a facility, 44 (10%). Patients with a fall history (OR: 2.95, 95% CI: 1.56, 5.57), utilizing a mobility aid (OR: 6.0, 95% CI: 2.8, 12.83), were partial or totally dependent (OR: 4.83, 95% CI: 2.29, 10.17), or who lived alone (OR: 2.57, 95% CI: 1.08, 6.07) had higher rates of discharge to a facility.

DISCUSSION

Preoperative mobility compromise and functional dependence are associated with higher rates of discharge to a facility. These preoperative factors are possibly modifiable with multidisciplinary care teams to decrease risks of facility placement.

Octogenarians unable to return home by postoperative-day 30

BACKGROUND

For older adults undergoing surgery, returning home is instrumental for functional independence. We quantified octogenarians unable to return home by POD-30, assessed geriatric factors in a predictive model, and identified risk factors to inform decision-making and quality improvement.

METHODS

This retrospective cohort study examined patients ≥80 years old from the ACS NSQIP Geriatric Surgery Pilot, using sequential logistic regression modelling. The primary outcome was non-home living location at POD-30.

RESULTS

Of 4946 patients, 19.8 ​% lived in non-home facilities at POD-30. Increased odds of non-home living location were seen in patients with preoperative fall history (OR 2.92, 95%CI 2.06-4.14) and new postoperative pressure ulcer (OR 2.66, 95%CI 1.50-4.71) Other significant geriatric-specific risk factors included mobility aid use, surrogate-signed consent, and postoperative delirium, with odds ratios ranging from 1.42 (1.19-1.68) to 1.97 (1.53-2.53).

CONCLUSIONS

These geriatric-specific risk factors highlight the importance of preoperative vulnerability screening and intervention to inform surgical decision-making.

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020)

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

Development and Validation of a Novel Preoperative Risk Score to Identify Patients at Risk for Nonhome Discharge after Elective Endovascular Aortic Aneurysm Repair (EVAR)

BACKGROUND

Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after elective endovascular aortic repair (EVAR) is uncommon. However, NHD after surgery has an important impact on patient quality of life and postdischarge outcomes. Understanding factors that put patients undergoing EVAR at high risk for NHD is essential to providing adequate preoperative counseling and shared decision making. This study aimed to identify independent predictors of NHD following elective EVAR and to create a clinically useful preoperative risk score.

METHODS

Elective EVAR cases were queried from the Society for Vascular Surgery Vascular Quality Initiative 2014-2018. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed.

RESULTS

Overall, 24,426 patients were included and 932 (3.8%) required NHD. Multivariable analysis in the development group identified independent predictors of NHD, which were used to create a 20-point risk score. Patients were stratified into 3 groups based upon their risk score: low risk (0-7 points; n = 16,699) with an NHD rate of 1.8%, moderate risk (8-13 points; n = 7,315) with an NHD rate of 7.3%, and high risk (≥14 points; n = 412) with an NHD rate of 21.8%. The risk score had good predictive ability with c-statistic = 0.75 for model development and c-statistic = 0.73 in the validation dataset.

CONCLUSIONS

This novel risk score can predict NHD following EVAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

A history of bariatric surgery before surgery for colorectal cancer may improve short-term postoperative outcomes: Analysis of the national inpatient sample 2015-2019

BACKGROUND

Bariatric surgery is the most effective and sustainable form of weight loss. Bariatric surgery before elective operations for colorectal pathology may improve postoperative outcomes. To compare patients with and without prior bariatric surgery undergoing surgery for colorectal cancer in terms of postoperative morbidity and health care use.

METHODS

Adult patients undergoing resection for colorectal cancer from 2015 to 2019 were identified from the National Inpatient Sample. Patients were stratified according to their history of bariatric surgery. Propensity score matching with 4:1 nearest-neighbor matching was performed according to demographic, operative, and hospital characteristics. The primary outcome was postoperative morbidity. Secondary outcomes included system-specific postoperative complications, postoperative mortality, postoperative length of stay, total admission health care cost, and post-discharge disposition. McNemar's test and Wilcoxon matched-pairs signed-rank test were performed.

RESULTS

After propensity score matching, 1,197 patients without prior bariatric surgery and 376 patients with prior bariatric surgery were included. Patients with prior bariatric surgery had an absolute reduction of 6.5% in overall in-hospital postoperative morbidity (19.1% vs 25.6%, P < .0001), a $5,256 decrease in hospitalization cost ($70,344 vs $75,600, P = .034), and were more likely to be discharged home after their index operation (72.9% vs 63.9%, P < .0001).

CONCLUSION

Bariatric surgery before surgery for colorectal cancer may be associated with decreased postoperative morbidity and health care use. Bariatric surgery and other forms of rapid and effective weight loss, such as very low-energy diets, should be evaluated further for the optimization of obese patients before nonbariatric abdominal surgery.

Older age impacts outcomes after adrenalectomy

BACKGROUND

Adrenalectomy is well tolerated with low complication rates. It is unclear if these excellent outcomes are consistent across all age groups.

METHODS

The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were used. Patients who underwent adrenalectomy were identified and grouped based on age: ≤60, 61 to 70, 71 to 80, and >80 years. Patient characteristics, surgical indications, operative characteristics, and postoperative outcomes were compared between age groups. Primary outcome measures were mortality, morbidity, postoperative length of stay, non-home discharge, and unplanned readmission. Multivariable logistic regression analysis was performed.

RESULTS

Adrenalectomy was performed on 6,114 patients. Younger patients more frequently had surgery for non-functional benign neoplasms compared with older (55.7% vs 52.8% vs 45.9% vs 45.3%, for patients ≤60, 61 to 70, 71 to 80, and >80 years, respectively, P < .001), and less frequently had surgery for malignancy (8.8% vs 14.4% vs 22.5% vs 24.5%, P < .001). The median length of stay for patients ≤60 was 1 day compared with 2 days for patients 61-70, 71-80, and >80 (P < .001). The overall mortality rate was <1% and did not differ based on age (P = .18). Morbidity occurred less frequently in the younger age groups (7.3% vs 8.9% vs 11.2% vs 16.0%, P < .001) compared with older. Similar trends were seen for non-home discharge (1.4% vs 2.5% vs 4.8% vs 17.0%, P < .001). On multivariable analysis, patients aged >80 had a 2-fold increased likelihood of morbidity and a 9-fold increased likelihood of non-home discharge compared to patients aged ≤60.

CONCLUSION

Older age is associated with morbidity and non-home discharge after adrenalectomy. Knowledge of these risks is critical when counseling an aging surgical population.

Nonhome Discharge in Patients Undergoing Pelvic Reconstructive Surgery: A National Analysis

IMPORTANCE

Discharge to home after surgery has been recognized as a determinant of long-term survival and is a common concern in the elderly population.

OBJECTIVE

The aim of the study was to determine the incidence and risk factors for nonhome discharge in patients undergoing major surgery for pelvic organ prolapse.

STUDY DESIGN

We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2018. We included patients who underwent sacrocolpopexy, vaginal colpopexy, and colpocleisis. We compared perioperative characteristics in patients who were discharged home versus those who were discharged to a nonhome location. Stepwise backward multivariate logistic regression was then used to control for confounding variables and identify independent predictors of nonhome discharge.

RESULTS

A total of 38,012 patients were included in this study, 209 of whom experienced nonhome discharge (0.5%). Independent predictors of nonhome discharge included preoperative weight loss (adjusted odds ratio [aOR], 5.9; 95% confidence interval [CI], 1.3-27.5), dependent health care status (aOR, 5.0; 95% CI, 2.6-9.5), abdominal hysterectomy (aOR, 2.3; 95% CI, 1.4-3.7), American Society of Anesthesiologists class 3 or greater (aOR, 2.0; 95% CI, 1.5-2.7), age (aOR, 1.1; 95% CI, 1.05-1.09), operative time (aOR, 1.005; 95% CI, 1.003-1.006), laparoscopic hysterectomy (aOR, 0.6; 95% CI, 0.4-1.0), and laparoscopic sacrocolpopexy (aOR, 0.5; 95% CI, 0.3-0.8).

CONCLUSIONS

In patients undergoing surgery for pelvic organ prolapse, nonhome discharge is associated with various indicators of frailty, including age, health care dependence, and certain comorbidities. An open surgical approach increases the risk of nonhome discharge, while a laparoscopic approach is associated with lower risk.

Predictors of discharge to home following major surgery for urologic malignancies: Results from the national surgical quality improvement program

OBJECTIVES

To identify patient risk factors that predict nonhome discharge after surgery for urologic malignancies as well as determine whether discharge status had an impact on readmission rates in patients undergoing surgery for urologic malignancies.

METHODS

We identified patients who had undergone surgery for urologic malignancies including prostate, bladder, kidney, or upper tract urothelial cancer from 2011 to 2019 in the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) database. Multivariable logistic regression analyses were performed to identify patient characteristics that were associated with nonhome discharges and 30-day postoperative readmission.

RESULTS

Nonhome discharge occurred in 2.8% of our study population. Women were less likely to be discharged to home (OR 0.60 p < 0.0001). Nonhome discharge was more common in patients who underwent cystectomy when compared to nephrectomy (OR 1.41 p < 0.0001) or prostatectomy (OR 4.16 p < 0.0001). Those with elevated BMI were less likely to experience non-home discharge (OR 0.86 p=0.0095) while patients who were identified as underweight and those with unexpected weight loss prior to surgery were more likely to have nonhome discharges (OR 1.76 p = 0.0002, OR 1.67, p < 0.0001). Comorbidities and presence of postoperative complications were also found to be significant independent predictors of nonhome discharges. Thirty-day postoperative readmission occurred in 6.9% of our study population. Of the patients who were readmitted 93.1% were initially discharged home, and 6.9% had nonhome discharges. Higher risk of readmission was seen in elderly patients and those with significant comorbidities. When controlling for predictors of readmission, on multivariate analysis, non-home discharge was associated with a decreased likelihood of readmission (OR 0.79, p = 0.0004).

CONCLUSIONS

Patient factors including age, gender, weight, comorbidities, postoperative complications, and site of procedure were found to be independent predictors of non-home discharge following surgery for urologic malignancies. Patients with these risk factors should be counseled preoperatively on the likelihood of requiring a non-home discharge to help manage expectations and create a standardized transition of care pathway following surgery.

Minimally Invasive Compared to Open Colorectal Cancer Resection for Older Adults: A Population-based Analysis of Long-term Functional Outcomes

OBJECTIVE

We sought to compare long-term healthcare dependency and time-at-home between older adults undergoing minimally invasive surgery (MIS) for colorectal cancer (CRC) and those undergoing open resection.

BACKGROUND

Although the benefits of MIS for CRC resection are established, data specific to older adults are lacking. Long-term functional outcomes, central to decision-making in the care for older adults, are unknown.

METHODS

We performed a population-based analysis of patients ≥70years old undergoing CRC resection between 2007 to 2017 using administrative datasets. Outcomes were receipt of homecare and "high" time-at-home, which we defined as years with ≤14 institution-days, in the 5years after surgery. Homecare was analyzed using time-to-event analyses as a recurrent dichotomous outcome with Andersen-Gill multivariable models. High timeat-home was assessed using Cox multivariable models.

RESULTS

Of 16,479 included patients with median follow-up of 4.3 (interquartile range 2.1-7.1) years, 7822 had MIS (47.5%). The MIS group had lower homecare use than the open group with 22.3% versus 31.6% at 6 months and 14.8% versus 19.4% at 1 year [hazard ratio 0.87,95% confidence interval (CI) 0.83-0.92]. The MIS group had higher probability ofhigh time-at-home than open surgery with 54.9% (95% CI 53.6%-56.1%) versus 41.2% (95% CI 40.1%-42.3%) at 5years (hazard ratio 0.71, 95% CI 0.68-0.75).

CONCLUSIONS

Compared to open surgery, MIS for CRC resection was associated with lower homecare needs and higher probability of high time-at-home in the 5 years after surgery, indicating reduced long-term functional dependence. These are important patient-centered endpoints reflecting the overall long-term treatment burden to be taken into consideration in decision-making.

Impact of Patient, Surgical, and Perioperative Factors on Discharge Disposition after Radical Cystectomy

Radical cystectomy (RC) is a complex procedure associated with lengthy hospital stays and high complication and readmission rates. We evaluated the impact of patient, surgical, and perioperative factors on discharge disposition following RC at a tertiary referral center. From 2012 to 2019, all bladder cancer patients undergoing RC at our institution were identified (n = 1153). Patients were classified based on discharge disposition: to home or to continued facility-based rehabilitation centers (CFRs, n = 180 (15.61%) patients). On multivariate analysis of patient factors only, age [Risk Ratio (RR): 1.07, p < 0.001)], single marital status (RR: 1.09, p < 0.001), and living alone prior to surgery (RR: 2.55, p = 0.004) were significant predictors of discharge to CFRs. Multivariate analysis of patient, surgical, and perioperative factors indicated age (RR: 1.09, p < 0.001), single marital status (RR: 3.9, p < 0.001), living alone prior to surgery (RR: 2.42, p = 0.01), and major post-operative (Clavien > 3) complications (RR: 3.44, p < 0.001) were significant independent predictors of discharge to CFRs. Of note, ERAS did not significantly impact discharge disposition. Specific patient and perioperative factors significantly impact discharge disposition. Patients who are older, living alone prior to surgery, and/or have a major post-operative complication are more likely to be discharged to CFRs after RC.

Evaluating the Impact of Preoperative Geriatric-Specific Variables and Modified Frailty Index on Postoperative Outcomes After Elective Pancreatic Surgery

BACKGROUND

Pursuing pancreatic resection in elderly patients is often complex and limited by concern for functional status and postoperative risk. This study examines the associations between two different preoperative functional status metrics with postoperative outcomes in the geriatric population.

METHODS

Patients who participated in the ACS NSQIP Geriatric Surgery Research File pilot program (2014-2018) undergoing elective pancreatic operations were included. Two clinically meaningful functional status scores were calculated: the presence of one or more geriatric-specific variable (GSV) and a 5-factor modified frailty index (mFI-5). Multivariable logistic regression adjusting for ACS NSQIP-estimated risk was performed to evaluate associations between preoperative GSV, mFI-5 and 30-day outcome measures.

RESULTS

A total of 1266 patients were included: 808 (64%) age 65-74, 302 (24%) age 75-80, and 156 (12%) age ≥ 81; 843 (67%) patients underwent pancreatoduodenectomy. Operations were performed for pancreatic adenocarcinoma in 712 (56%) patients. Older patients had greater likelihood of postoperative morbidity (35% vs 31% vs 47%, by age group, p = 0.004) and discharge to a facility (12% vs 23% vs 48%, by age group, p < 0.001). Adjusting for ACS NSQIP predicted risk, patients with a preoperative GSV were more likely to require reoperation and discharge to a facility (OR 1.81 [95% CI 1.03-3.16] and 3.95 [95% CI 2.91-5.38], respectively). The mFI-5 was not associated with postoperative outcomes (all p ≥ 0.18).

CONCLUSION

The presence of a preoperative GSV is associated with reoperation and discharge to a skilled facility following elective pancreatic resection. Geriatric-specific variables should be considered in joint preoperative decision making to optimize care.

Prehabilitation, enhanced recovery after surgery, or both? A narrative review

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.

Functional and Cognitive Decline Among Older Adults After High-risk Surgery

OBJECTIVE

The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use.

SUMMARY BACKGROUND DATA

Patient-centered outcomes after surgery are poorly characterized.

METHODS

Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use.

RESULTS

The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001).

CONCLUSION

Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.

Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer

BACKGROUND

Patients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes.

METHODS

The New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery.

RESULTS

In total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03-4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21-0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36-0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22-0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33-0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001).

CONCLUSION

Factors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.

Patient reported outcomes in an elder-friendly surgical environment: Prospective, controlled before-after study

Introduction

The Acute Care for the Elderly (ACE) model has demonstrated clinical benefit, but there is little evidence regarding quality of life after discharge. The Elder-friendly Approaches to the Surgical Environment (EASE) study was conducted to assess implementation of an ACE unit on an acute surgical service. Improved clinical and economic outcomes have been demonstrated, but post-discharge patient reported outcomes have not yet been reported.

Methods

Prospective, concurrently controlled, before-after study at two tertiary care hospitals in Alberta, Canada. The SF-12, EQ-5D, Canadian Malnutrition Screening Tool (CMST) and patient satisfaction were collected from elderly (≥ 65 years old) patients, 6 weeks and 6 months after discharge from an acute care surgical service. A difference-in-difference (DID) method was used to analyze between-site effects.

Results

At six weeks, patient satisfaction was high at 68%-86%, with significant improvement Pre-to Post-EASE at the control site (p < 0.001), but not the intervention site (p = 0.06). For the intervention site, within-site adjusted pre-post effects were nonsignificant for all patient reported outcomes [EQ-Index Score β coefficient (SE): 0.042 (0.022); EQ-Visual Analog Scale: 0.10 (2.14); SF-12 Physical Component Score: -0.57 (0.84); SF-12 Mental Component Score: 1.17 (0.84); CMST Score: -0.39 (0.34)]. DID analyses were also non significant for all outcomes except for SF-12 Mental Component Score (p < 0.001).

Conclusion

The clinically and economically beneficial EASE interventions do not appear to compromise quality of life, risk for malnutrition, or patient satisfaction in the post-discharge period. Further research with larger sample size is needed with comparisons to pre-intervention and the early post-discharge period.

Evaluation of Factors Associated with, and Outcomes for Patients with Nonhome Discharge Destinations Following Carotid Endarterectomy

INTRODUCTION

Following a carotid endarterectomy (CEA) procedure, patients are discharged to their homes or other locations than home such as an acute care facility or skilled nursing facility based on their functional status and level of medical attention needed. Decision-making for discharge destination following a CEA to home or nonhome locations is important due to the differences in survival and postoperative complications. While primary outcomes such as mortality and occurrence of stroke following CEA have been extensively studied, there is a paucity of information characterizing outcomes of discharge destination and the factors associated. The purpose of this study was to explore the factors associated with discharge to nonhome destinations after CEA, and outcomes after discharge.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent CEA from 2011 to 2018. Patients were divided into two groups based on their discharge destination (home versus nonhome). Univariate and multivariate analysis were performed for preoperative and intraoperative factors associated with different discharge destinations. Postoperative complications associated with discharge to nonhome destinations were analyzed and mortality after discharge from hospital was compared between the 2 groups.

RESULTS

A total of 25,094 patients met the criteria for inclusion in the study, of which 39% were females and 61% were males; median age was 71 years. Twenty four thousand one hundred twenty-five patients (93.13%) were discharged to home (Group I) and 1,779 (6.87%) were discharged to nonhome destinations (Group II). Following preoperative and intraoperative factors were associated with discharge to nonhome locations: older age, diabetes mellitus, functional independent status, transfer from other hospitals, symptomatic status, need for preoperative blood transfusions, severe ipsilateral carotid stenosis, elective CEA, need for intraoperative shunt and general anesthesia (all P< 0.05). Following postoperative complications had statistically significant association with discharge to nonhome destinations: postoperative blood transfusion, pneumonia, unplanned intubation, longer than 48 hours on ventilator, development of stroke, myocardial infarction, deep vein thrombosis, and sepsis (all P< 0.05). Mortality after discharge from hospital was 0.39% (n = 100). Mortality among those who were discharged to home was 0.29% vs. 1.63% for those who were discharged to nonhome locations (P< 0.05).

CONCLUSIONS

Majority of the patients after CEA are discharged back to their homes. This study identifies the factors which predispose patients discharged to locations, other than home. Patients who are not discharged home have higher mortality as compared to those who are discharged to their homes.

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse

AIM

Despite the financial and value-based implications associated with higher levels of care at discharge, few studies have evaluated modifiable treatment factors that may optimize postacute care. The aim of this work was to assess the association between operative approach and disposition to a higher level of care and other outcomes following surgery for rectal prolapse.

METHOD

Using a retrospective cohort study design, the database of the National Surgical Quality Improvement Program was used to identify patients with rectal prolapse who underwent perineal repair or open or laparoscopic rectopexy with or without resection between 2012 and 2017. Discharge destination and 30-day postoperative outcomes were compared using propensity score mathcing and weighting. Nomograms generated using multivariable regression calculated the risk of requiring higher levels of care upon discharge and morbidity.

RESULTS

Propensity-score analysis included 3000 patients [1500 in the perineal group, 580 in the open abdominal group and 920 in the minimally invasive (MIS) group]. Patients who received open abdominal surgery were more likely to require elevation of care at destination compared with those who received perineal surgery (OR 1.65, 95% CI 1.22-1.24) and MIS abdominal surgery (OR 1.80, 95% CI 1.18-2.76). Similar effects were seen for overall morbidity. Increased age, higher American Society of Anesthesiologists class, congestive heart failure, dependent functional status and open surgery were independent predictors of discharge to higher level of care (c-statistic = 0.79).

CONCLUSION

Open surgery compared with MIS and perineal surgery was associated with higher levels of discharge disposition following rectal prolapse surgery. Future research should continue to identify modifiable treatment factors that reduce poor postoperative outcomes among patients with rectal prolapse.

Preoperative functional status is associated with discharge to nonhome in geriatric individuals

INTRODUCTION

Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations.

MATERIALS AND METHODS

A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression.

RESULTS

The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01).

CONCLUSION

Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes.

Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair

BACKGROUND

Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair.

METHODS

Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis.

RESULTS

There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87).

CONCLUSIONS

In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.

Unplanned readmission after emergency laparotomy: A post hoc analysis of an EAST multicenter study

BACKGROUND

Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient.

METHODS

This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers enrolled all adult patients undergoing emergency laparotomies and systematically collected preoperative, operative, and 30-day postoperative variables. For the purpose of this study, we defined unplanned readmission as a readmission occurring within 30 days from discharge and one that was immediately preceded by an emergency department visit. Patients were excluded if they died during the index admission, were discharged to hospice, or were transferred to other hospitals. Predictors of unplanned readmission were evaluated using a multivariable logistic regression model, adjusting for patient demographics, comorbidities, laboratory variables, and preoperative acuity of disease variables.

RESULTS

A total of 1,347 patients were included, of which 234 (17.4%) had an unplanned readmission. The median patient age was 60 y, 49.4% were male, and 71.4% were white. The most common diagnoses were hollow viscus perforation (28.1%) and small bowel obstruction (24.5%). Predictors of unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, confidence interval: 1.35-3.64, P = .002], weight loss >10% in the past 6 months [odds ratio: 1.65, confidence interval: 1.07-2.54, P = .023], dyspnea at baseline [odds ratio: 1.62, confidence interval: 1.06-2.48, P = .026], wound complications [odds ratio: 2.23, confidence interval: 1.55-3.19, P < .001], and discharge to nursing homes [odds ratio: 1.68, confidence interval: 1.02-2.80, P = .044]).

CONCLUSION

Unplanned readmission after emergency laparotomies are common, especially for patients with wound complications or requiring nursing homes. These system factors are potential quality improvement targets to reduce readmissions.

Patients with depression are less likely to go home after critical limb revascularization

BACKGROUND

Although often overlooked during the preoperative evaluation, recent evidence has suggested that depression in patients with peripheral artery disease is associated with increased postoperative complications, including decreased primary and secondary patency after revascularization and an increased risk of major amputation and mortality. Postoperative nonhome discharge (NHD) is an important outcome for patients and has also been associated with other adverse outcomes; however, the effect that depression has on NHD after vascular surgery has remained unexplored. We hypothesized that depression would be associated with an increased risk of NHD after revascularization for chronic limb threatening ischemia (CLTI).

METHODS

Endovascular, open, and hybrid (combined open and endovascular) cases of revascularization for CLTI were identified from the 2012 to 2014 National (Nationwide) Inpatient Sample. CLTI, diagnoses of depression, and medical comorbidities were defined using the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes. A hierarchical multivariable binary logistic regression controlling for hospital level variation and for confounders meeting P <.01 on bivariate analysis was used to examine the association between depression and NHD. A sensitivity analysis after coarsened exact matching for baseline characteristics that differed between the two groups was performed to reduce any imbalance.

RESULTS

A total of 64,817 cases were identified, of which 5472 (8.4%) included a diagnosis of depression and 16,524 (25.5%) NHD. The patients with depression were younger and more likely to be women and white, have multiple comorbidities and a nonelective admission, and experience a postoperative complication (P <.05). On unadjusted analyses, patients with depression had an 8% absolute increased risk of requiring NHD (32.1% vs 24.9%; P <.001). On multivariable analysis, patients with depression had an increased odds for NHD (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.40-1.61; c-statistic, 0.81) compared with those without depression. After stratification by operative approach, depression had a larger effect estimate in endovascular revascularization (OR, 1.57; 95% CI, 1.42-1.74) compared with open (OR, 1.45; 95% CI, 1.30-1.62). A test for interaction between depression and gender identified that men with depression had greater odds of NHD compared with women with depression (OR, 1.68; 95% CI, 1.51-1.88; vs OR, 1.37; 95% CI, 1.25-1.51; interaction P <.01). A sensitivity analysis after coarsened exact matching confirmed these findings.

CONCLUSIONS

To the best of our knowledge, the present study is the first to identify an association between depression and NHD after revascularization for CLTI. These results provide further evidence of the negative effects that comorbid depression has on patients undergoing revascularization for CLTI. Future studies should examine whether treating depression can improve the outcomes in this patient population.

A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair

BACKGROUND

Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score.

METHODS

Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed.

RESULTS

Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset.

CONCLUSIONS

This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Risk Factors for Post-acute care Following Free Flap Reconstruction of the Oral Cavity

OBJECTIVE

Identify previously unreported factors that predict the need for post-acute care after free flap reconstruction of the oral cavity.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single academic medical center.

METHODS

A total of 134 patients with head and neck disease involving the oral cavity underwent free tissue transfer for reconstruction between August 2012 and October 2015. All patients had a tracheostomy placed at the time of surgery. Data were collected, including demographics, perioperative risk factors, and social variables. Univariate and multivariate logistic regression were used to identify risk factors for needing post-acute care.

RESULTS

Of 134 patients, 37 (28%) required post-acute care upon discharge, and 97 of 134 (72%) were discharged home with assistance. Multivariate logistic regression revealed that lack of family support (adjusted odds ratio [AOR], 32.12; 95% CI, 13.75-274.90; P = .002), tracheostomy tube at discharge (AOR, 13.70; 95% CI, 3.20-58.44; P < .001), government insurance (AOR, 3.85; 95% CI, 1.13-13.11; P = .031), hospital stay >10 days (AOR, 3.52; 95% CI, 1.25-9.90; P = .017), and increasing age (AOR, 1.11; 95% CI, 1.04-1.18; P = .003) were significantly associated with post-acute care need.

CONCLUSION

Lack of family support, tracheostomy tube at discharge, government insurance, hospital stay >10 days, and increasing age are independently associated with the need for post-acute care following free flap reconstruction of the oral cavity. Physicians, social workers, and nurse case managers are positioned to identify patients at high risk for needing post-acute care and to reduce the duration of hospitalizations.

Predictors of Non-home Discharge after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Using a national database of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) recipients, we sought to determine risk factors for nonhome discharge (NHD) in a cohort of patients.

METHODS

Patients undergoing CRS/HIPEC at any one of 12 participating sites between 2000 and 2017 were identified. Univariate analysis was used to compare the characteristics, operative variables, and postoperative complications of patients discharged home and patients with NHD. Multivariate logistic regression was used to identify independent risk factors of NHD.

RESULTS

The cohort included 1593 patients, of which 70 (4.4%) had an NHD. The median [range] peritoneal cancer index in our cohort was 14 [0-39]. Significant predictors of NHD identified in our regression analysis were advanced age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < 0.001), an American Society of Anesthesiologists (ASA) score of 4 (OR, 2.87; 95% CI, 1.21-6.83; P = 0.017), appendiceal histology (OR, 3.14; 95% CI 1.57-6.28; P = 0.001), smoking history (OR, 3.22; 95% CI, 1.70-6.12; P < 0.001), postoperative total parenteral nutrition (OR, 3.14; 95% CI, 1.70-5.81; P < 0.001), respiratory complications (OR, 7.40; 95% CI, 3.36-16.31; P < 0.001), wound site infections (OR, 3.12; 95% CI, 1.58-6.17; P = 0.001), preoperative hemoglobin (OR, 0.81; 95% CI, 0.70-0.94; P = 0.006), and total number of complications (OR, 1.41; 95% CI, 1.16-1.73; P < 0.001).

CONCLUSIONS

Early identification of patients at high risk for NHD after CRS/HIPEC is key for preoperative and postoperative counseling and resource allocation, as well as minimizing hospital-acquired conditions and associated health care costs.

Short-term versus long-term trauma mortality: A systematic review

BACKGROUND

Trauma is the leading cause of death in the United States for persons under 44 years and the fourth leading cause of death in the elderly. Advancements in clinical care and standardization of treatment protocols have reduced 30-day trauma mortality to less than 4%. However, these improvements do not seem to correlate with long-term outcomes. Some reports have shown a greater than 20% mortality rate when looking at long-term outcomes. The aim of this study was to systematically review the incongruence between short- and long-term mortality for trauma patients.

METHODS

For this systematic review, we searched the Cochrane Library, EMBASE, Ovid Medline, Google Scholar, and Web of Science database to obtain relevant English, German, French, and Portuguese articles from 1965 to 2018.

RESULTS

Trauma patients have decreased long-term survival when compared to the general population and when compared with age-matched cohorts. Postdischarge trauma mortality is significantly higher (mean, 4.6% at 3-6 months, 15.8% at 2-3 years, 26.3% at 5-25 years) compared with controls (mean, 1.3%, 2.2%, and 15.6%, respectively). Patient comorbidities likely contribute to long-term trauma deaths. Trauma patients discharged to a skilled nursing facility have worse mortality compared with those discharged either to home or a rehabilitation center. In contrast to data available which illustrate that short-term mortality has improved, quality of evidence was not sufficient to determine if any improvements in long-term trauma mortality outcomes have also occurred.

CONCLUSIONS

The decreased short-term mortality observed in trauma patients does not appear correlated with decreased long-term mortality. The extent to which increased long-term trauma mortality is related to the initial traumatic insult-versus rising population age and comorbidity burden as well as suboptimal discharge location-requires further study.

LEVEL OF EVIDENCE

Systematic Review, level IV.

Safety of Major Abdominal Operations in the Elderly: A Study of Geriatric-Specific Determinants of Health

BACKGROUND

Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations.

METHODS

Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination.

RESULTS

A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p < 0.001). After adjustment for ACS NSQIP-estimated probabilities of morbidity or mortality, no geriatric-specific preoperative risk factors were significantly associated with increased risk of death or complications in any age group (all p > 0.055). Patients 75-84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p < 0.001) compared to patients 65-74 years. All geriatric-specific variables: use of mobility aid, living alone, consent signed by a surrogate, and fall history, were significantly associated with discharge to a facility (all p ≤ 0.001).

CONCLUSIONS

After adjusting for comorbid conditions, geriatric-specific variables are not associated with postoperative mortality and morbidity among elderly patients; however, geriatric-specific variables are significantly associated with discharge to a facility.

Outcomes of vulnerable elderly patients undergoing elective major surgery: a prospective cohort study

PURPOSE

Identifying patients at risk of postoperative complications and trying to prevent these complications are the essence of preoperative evaluation. While not overtly frail or disabled, vulnerable patients with mild frailty may be missed by routine assessments and may still have a worse postoperative course.

METHODS

We performed a prospective cohort study evaluating vulnerability in older patients undergoing elective surgery. Vulnerability was assessed using the Clinical Frailty Scale. Our primary outcome was postoperative hospital length of stay (LOS) and our secondary outcome was non-home hospital discharge. We performed multivariable analyses to assess the association between vulnerability and our primary and secondary outcome.

RESULTS

Between 1 January 2017 and 1 January 2018, 271 older patients with a median [interquartile range (IQR)] age of 72 [69-76] yr underwent frailty assessment prior to surgery. Eighty-eight (32.5%) of the cohort were classified as vulnerable. The median [IQR] duration of hospital LOS was 4 [2-7] days for vulnerable patients, 4 [2-6] days for robust patients, and 7 [3-10] days for frail patients. After adjusting for confounders, hospital LOS was not longer for vulnerable patients than for robust patients, but was associated with a higher rate of non-home discharge (odds ratio, 3.7; 95% confidence interval, 1.1 to 12.9; P = 0.04).

CONCLUSIONS

Vulnerability was not associated with a longer hospital LOS but with higher risk of non-home discharge. Vulnerable patients might benefit from early identification and advanced planning with earlier transfer to rehabilitation centres.

Discharge destination following rectal cancer resection: an analysis of preoperative and intraoperative factors

PURPOSE

Rectal cancer resections can be associated with long and complicated postoperative recoveries. Many patients undergoing these operations are discharged to rehabilitation or skilled nursing facilities. The purpose of this study was to identify preoperative and intraoperative factors associated with increased risk for non-home discharge after rectal cancer resection.

METHODS

Rectal cancer resections were identified in the National Surgical Quality Improvement Program Targeted Proctectomy Dataset (years 2016 through 2017) by ICD code. Patients with unknown discharge destination or who experienced in-hospital mortality were excluded. Univariate and multivariate logistic regression analyses were performed to identify preoperative and intraoperative variables associated with non-home discharge destination. Multiple imputation was used to account for missing values.

RESULTS

Among the 3637 patients comprising the study sample, 292 (8.0%) patients were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariate analysis included older age, non-independent functional status, insulin-dependent diabetes, and hypoalbuminemia (all p < 0.05). Having received neoadjuvant chemotherapy was associated with home discharge (OR 0.625, 95% CI 0.427-0.914, p = 0.015). Intraoperative factors associated with non-home discharge on multivariate analysis were concurrent cystectomy (p = 0.004) and myocutaneous flap reconstruction (p < 0.001). Patients discharged to non-home facilities had longer initial lengths of stay (14.1 versus 7.0 days, p < 0.001) and higher reoperation rates (12.7 versus 5.0%, p < 0.001), but similar readmission rates (14.7 versus 15.0%, p = 1.0).

CONCLUSION

Several preoperative and intraoperative factors are associated with increased risk for non-home discharge after rectal cancer resection. These data can aid in perioperative planning and discharge optimization.

Assessment of poor functional status and post-acute care needs following primary ovarian cancer debulking surgery

INTRODUCTION

Poor baseline functional status is associated with adverse surgical outcomes. Additionally, decline in the postoperative setting may result in the delay of additional treatments, impacting overall survival. This study assesses the incidence and risk factors for functional decline following primary ovarian cancer debulking surgery in previously independent women using discharge location as a surrogate.

METHODS

All patients with a postoperative diagnosis of ovarian cancer who underwent surgical debulking and had documentation of discharge location were identified using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program database. Patients were excluded if their baseline functional status was dependent or partially dependent, or if they died before discharge. Discharge destination was dichotomized as home versus non-home. Descriptive data included demographics, comorbidities, and perioperative outcomes. Multivariable logistic regression was used to evaluate the association of clinical and surgical factors on discharge destination.

RESULTS

1786 patients met the criteria for analysis; 120 (6.7%) patients were discharged to non-home. Differences between home and non-home discharges included age (53.2% vs 83.3% ≥60), body mass index (26.5 vs 27.8 median), comorbidities (45.2% vs 64.2% with ≥1), and complications (8.6% vs 30.0% with ≥1, all p<0.05). In multivariable logistic regression analyses, only increasing age and complications were independently associated with discharge to non-home. Those age ≥70 had 9.0 times the risk (95% CI 3.5 to 23.4; p<0.001) as age <50. The presence of one or more postoperative complications carried 4.5 times (95% CI 2.9 to 7.0; p<0.001) the risk of those without complications. 30 day mortality was also increased in patients discharged to non-home.

DISCUSSION

6.7% of previously independent ovarian cancer patients were discharged to non-home following surgery. Major risk factors for non-home include older age, comorbidities, and postoperative complications. Efforts to optimize baseline functional status and minimize surgical complications may improve discharge rates to non-home and postoperative functional status.

The Assessment of Complications After Major Abdominal Surgery: A Comparison of Two Scales

BACKGROUND

An accurate and reproducible method for the evaluation of postoperative morbidity is essential for a valid assessment of the outcomes of surgery. However, there is still no consensus on reporting of complications. The Clavien-Dindo classification (CDC) of complications is a validated system which reports only the most severe complication. The Comprehensive Complication Index (CCI) is a novel scale designed to capture the overall burden of complications. The aim of our study is to validate and compare the CDC and the CCI in the setting of high-risk surgical patients in whom multiple complications are common.

METHODS

A prospective, observational study analyzed 206 high-risk adult patients undergoing major abdominal surgery. Each postoperative complication was recorded until discharge or readmission within 30 days. The severity of complications was graded with the CDC, and the CCI was calculated subsequently. Correlations of the CDC and the CCI with hospitalization indicators and functional activity on discharge were assessed and compared.

RESULTS

A total of 424 complications occurred in 125 (60.7%) patients. The median CCI for the cohort was 20.9 (0-44.9). CD grade II was the most frequent among patients with complications (62/125; 49.6%). The CCI and the CDC have shown a strong correlation (r = 0.969, P < 0.01). Both scales strongly correlated with the parameters of hospitalization, but the CCI showed a stronger correlation to the intensive care unit length of stay (LOS; 0.670 versus 0.628, P < 0.001), postoperative LOS (0.652 versus 0.630, P = 0.041), and prolonged intensive care unit LOS (0.604 versus 0.555, P < 0.001). The median CCI and the highest CD grade were significantly different respective to the functional activity on discharge (P < 0.001).

CONCLUSIONS

The CDC and the CCI are the effective methods for reporting of complications after major abdominal surgery. The CCI is a more accurate scale for use in high-risk patients and correlates better with the postoperative LOS.

Trauma Providers' Perceptions of Frailty Assessment: A Mixed-Methods Analysis of Knowledge, Attitudes, and Beliefs

OBJECTIVES

Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment.

METHODS

We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods.

RESULTS

One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members.

CONCLUSIONS

Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

Ultrasonic aspiration in neurosurgery: comparative analysis of complications and outcome for three commonly used models

Introduction

Ultrasonic aspiration (UA) devices are commonly used for resecting intracranial tumors, as they allow for internal debulking of large tumors, hereby avoiding damage to adjacent brain tissue during the dissection. Little is known about their comparative safety profiles.

Methods and materials

We analyzed data from a prospective patient registry. Procedures using one of the following UA models were included: Integra® CUSA, Söring®, and Stryker® Sonopet. The primary endpoint was morbidity at discharge, defined as significant worsening on the Karnofsky Performance Scale. Secondary endpoints included morbidity and mortality until 3 months postoperative (M3), occurrence, type, and etiology of complications.

Results

Of n = 1028 procedures, the CUSA was used in n = 354 (34.4 %), the Söring in n = 461 (44.8 %), and the Sonopet in n = 213 (20.7 %). There was some heterogeneity of study groups. In multivariable analysis, patients in the Söring (adjusted odds ratio (aOR) 1.29; 95 % confidence interval (CI), 0.80–2.08; p = 0.299), and Sonopet group (aOR, 0.86; 95 % CI, 0.46–1.61; p = 0.645) were as likely as patients in the CUSA group to experience discharge morbidity. At M3, patients in the Söring (aOR, 1.20; 95 % CI, 0.78–1.86; p = 0.415) and Sonopet group (aOR, 0.53; 95 % CI, 0.26–1.08; p = 0.080) were as likely as patients in the CUSA group to experience morbidity. There were also no differences for M3 morbidity in subgroup analyses for gliomas, meningiomas, and metastases. The grade (p = 0.608) and etiology (p = 0.849) of postoperative complications were similar.

Conclusions

Neurosurgeons select UA types with regard to certain case-specific characteristics. The safety profiles of three commonly used UA types appear mostly similar.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04021-0) contains supplementary material, which is available to authorized users.

Hospital experience predicts outcomes after high-risk geriatric surgery

BACKGROUND

Geriatric patients require specialized perioperative care, yet the impact of geriatric surgery proportion (a measure of experience) and geriatric surgery volume, on clinical outcomes is unknown. This study analyzes the association between proportion and volume and clinical outcomes after high-risk geriatric surgery.

METHODS

Using the 2014 National Inpatient Sample, hospital encounters for older adults (≥65 years) undergoing high-risk geriatric surgery were identified. Geriatric surgery volume was defined as a hospital's annual volume of geriatric patients undergoing high-risk geriatric surgery. Geriatric surgery proportion was calculated as volume divided by the sum of high-risk surgeries in all ages. Hierarchical multivariable regression models identified predictors of inpatient mortality, postoperative length of stay, and discharge to nursing facility.

RESULTS

There were an estimated 514,950 hospital encounters for older adults undergoing high-risk geriatric surgery from 3,115 hospitals. Mean proportion was 0.53 ± 0.19; median volume was 60 cases per year, ranging from 5 to 3,235. After adjustment, comparing the 90th to 10th percentiles, higher proportion was associated with decreased mortality (odds ratio [95% confidence interval] 0.81 [0.73-0.88]; P < .001) and shorter postoperative length of stay (-4.44% (-5.49 to -3.39%); P < .0001). Higher volume was not associated with mortality but was associated with longer length of stay (7.76% [6.75-8.77%]; P < .0001) and decreased discharge to nursing facility (0.87 [0.79-0.95]; P= .003).

CONCLUSION

Treatment of geriatric patients at hospitals with the highest proportion of high-risk geriatric surgery, or the most experience, is associated with improved outcomes. High-proportion hospitals should be examined to understand the mechanisms by which better quality geriatric surgical care is achieved, while lower-proportion hospitals may be targets for quality improvement efforts.

How Did We Get Here? A Broader View of the Postoperative Period

The decision to offer surgery to an older adult with medical comorbidities involves candid conversations between the surgeon, patient, and caregivers. Tools are available to physicians that facilitate patient empowerment. Beyond short-term risks, the conversation should include the potential for institutional discharge, functional and cognitive decline, and longer term mortality.

Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection

BACKGROUND

Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home.

OBJECTIVE

We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection.

DESIGN

This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns.

SETTINGS

Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals.

PATIENTS

Patients undergoing colon and rectal resections were included.

MAIN OUTCOME MEASURE

The main outcome measure was hospital use patterns of nonhome discharge.

RESULTS

Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045).

LIMITATIONS

This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size.

CONCLUSIONS

This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.

Assessment of clinical outcome of cholecystectomy according to age in preparation for the "Silver Tsunami"

BACKGROUND

Recent rapid increases in the aging population have created an impending "Silver Tsunami" in advanced countries. The overall prevalence of gallstone disease and its related complications will soon increase, and there will be a larger demand for gallbladder surgery.

METHODS

We examined the outcomes of cholecystectomy according to age among patients with cholelithiasis to determine how a patient's age influences the outcome of cholecystectomy. All patients with gallstone disease who presented for cholecystectomy at our institute from January 2006 to December 2018 were analyzed.

RESULTS

All perioperative outcomes (operation length, length of hospital stay, rate of open surgery, urgent surgery, postoperative complications, incidental gallbladder cancer, postoperative hospital death, concomitant bile duct stones, and total medical costs per patient) increased as patients aged.

CONCLUSIONS

To prevent the progression of biliary disease, elective laparoscopic cholecystectomy is recommended before patients with cholelithiasis advance in age.

A cost analysis of early biliary strictures following orthotopic liver transplantation in the United States

INTRODUCTION

To date, the financial burden of biliary strictures (BS) after orthotopic liver transplantation (OLT) has remained largely unassessed. This study sought to approximate perioperative costs associated with early BS and delineate where in the hospital these costs are incurred.

METHODS

The Premier Healthcare Database was queried for patients undergoing OLT between 2010 and 2016. Patients who did and did not develop early BS were compared with respect to perioperative costs and outcome variables. Multivariable regression models were used to estimate differences between groups.

RESULTS

Patients who developed early BS had a longer length of stay (LOS) (35.3 days vs 17.8 days, P < 0.001) and were less likely to be discharged home (odds ratio = 0.45, P = 0.003). Development of early BS was associated with an incremental cost increase of $81 881 (45.8%, P < 0.001). The greatest relative cost increases were in radiology (+163.5%) and respiratory therapy (+157.1%), while the greatest absolute increase was in room and board (+$27 589).

CONCLUSIONS

Early BS after OLT result in higher costs stemming from longer LOS and increased need for various diagnostic studies and therapies. In addition to incentivizing measures that may prevent early BS, hospitals should account for these factors when developing payment schemes for OLT with payors.

Predictive Risk Factors of Nonhome Discharge Following Elective Posterior Cervical Fusion

OBJECTIVE

To identify risk factors that are predictive of nonhome discharge after elective posterior cervical fusion.

METHODS

We performed a retrospective cohort study of adult patients who underwent elective posterior cervical fusion using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Patients were divided into 2 groups: home discharge and nonhome discharge. Univariate analysis was performed to compare incidence of 30-day postoperative complications between groups. Multivariate analysis was performed to identify complications that were predictive of nonhome discharge.

RESULTS

The cohort included 2875 patients; 24.1% were discharged to a nonhome facility, including skilled and nonskilled care facilities, nursing homes, assisted living facilities, and rehabilitation facilities. Nonhome discharge was associated with higher rates of 30-day pulmonary complication, cardiac complication, venous thromboembolism, urinary tract infection, blood transfusion, sepsis, and reoperation. Significant predictors of nonhome discharge were wound complication (odds ratio [OR] = 1.73; 95% confidence interval [CI], 1.07-2.80; P = 0.024), pulmonary complication (OR = 3.61; 95% CI, 1.96-6.63; P < 0.001), cardiac complication (OR = 6.13; 95% CI, 1.61-23.4; P = 0.008), venous thromboembolism (OR = 2.97; 95% CI, 1.43-6.19; P = 0.004), urinary tract infection (OR = 2.69; 95% CI, 1.50-4.82; P < 0.001), blood transfusion (OR = 1.70; 95% CI, 1.20-2.39; P = 0.003), sepsis (OR = 2.75; 95% CI, 1.25-6.02; P = 0.012), and prolonged length of stay (OR = 4.07; 95% CI, 3.34-4.95; P < 0.001).

CONCLUSIONS

Early identification of patients who are at high risk for nonhome discharge is important to implement early comprehensive discharge planning protocols and minimize hospital-acquired conditions related to prolonged length of stay and associated health care costs.

Predictors for Non-Home Patient Discharge Following Elective Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. The utilization of spinal surgery has increased and this trend is expected to continue. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement and reduce length of stay.

METHODS

The 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases, Ninth Revision diagnosis codes relevant to ASD. Patients were divided based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and hospital length of stay.

RESULTS

A total of 4552 patients met inclusion criteria, of which 1102 (24.2%) had non-home discharge. Multivariate regression revealed total relative value unit (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 1.00-1.01); female sex (OR = 1.54, 95% CI = 1.32-1.81); American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander versus black race (OR = 0.52, 95% CI = 0.35-0.78, P = .002); age ≥65 years (OR = 3.72, 95% CI = 3.19-4.35); obesity (OR = 1.18, 95% CI = 1.01-1.38, P = .034); partially/totally functionally dependent (OR = 2.11, 95% CI = 1.49-2.99); osteotomy (OR = 1.42, 95% CI = 1.12-1.80, P = .004) pelvis fixation (OR = 2.38, 95% CI = 1.82-3.11); operation time ≥4 hours (OR = 1.74, 95% CI = 1.47-2.05); recent weight loss (OR = 7.66, 95% CI = 1.52-38.65; P = .014); and American Society of Anesthesiologists class ≥3 (OR = 1.80, 95% CI = 1.53-2.11) as predictors of non-home discharge. P values were <.001 unless otherwise noted. Additionally, multivariate regression found non-home discharge to be a significant variable in prolonged length of stay.

CONCLUSIONS

The authors suggest these results can be used to inform patients preoperatively of expected discharge destination, anticipate patient discharge needs postoperatively, and reduce health care costs and morbidity associated with prolonged LOS.

Facility-Level Factors and Outcomes After Skilled Nursing Facility Admission for Trauma and Surgical Patients

OBJECTIVE

Patients discharged to skilled nursing facilities (SNFs) have worse outcomes than those discharged to home, but whether this is due to differences in facility-level factors in addition to patient characteristics is not known. We aimed to determine whether SNF-level factors including nurse staffing and patient density are associated with outcomes after acute hospitalization for trauma or surgery.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

Retrospective study of patients discharged to Medicare-certified SNFs after trauma or major surgery from 2007 to 2009. We measured the ratio of beds per nurse and the proportion of trauma and surgery patients at each facility (density). Outcomes were 1-year mortality, hospital readmission, and failure to discharge home at first discharge disposition.

RESULTS

For 389,133 patients (mean age 78 years, 63% female) admitted to 3707 SNFs, mortality was 26%, hospital readmission 26%, and failure to discharge home 44%. After adjusting for patient-level factors, SNFs with fewer beds per nurse had lower odds of mortality [odds ratio (OR): trauma 0.84; (95% confidence interval: 0.77-0.91), surgery 0.80 (0.75-0.86)], readmission [OR: trauma 0.81 (0.74-0.88), surgery 0.71 (0.65-0.76)], and failure to discharge home [OR: trauma 0.82 [0.74-0.91], surgery 0.66 [0.60-0.72]). SNFs with greater density of specialty patients (>4.3% surgery, >14.1% trauma) had lower odds of readmission [OR: trauma 0.59 (0.53-0.66), surgery 0.62 (0.58-0.67)] and failure to discharge home [OR: trauma 0.48 (0.43-0.55), surgery 0.45 (0.42-0.49)].

CONCLUSIONS

There are modifiable SNF-level factors that influence long-term outcomes and may be targets for intervention. Staffing standardization and SNF specialization may reduce variation of quality in post-acute care.

Hospital Readmissions After Urological Surgical Procedures in France: A Nationwide Cohort Study over 3 Years

BACKGROUND

Identifying the predictive factors for hospital readmission is required to target preventive measures.

OBJECTIVE

To assess the rate of surgical readmissions after a urological procedure and the risk factors associated with readmission.

DESIGN, SETTING, AND PARTICIPANTS

Data from all hospitalizations between January 2010 and November 2012 in France, regarding planned urological surgeries, were retrieved from the national medical database. To limit interactions between recent hospitalizations and surgical interventions, we selected only patients who were not hospitalized during the 12 mo preceding the urological procedure.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary outcome was the rate of readmissions within 30 d after urological surgery. The following risk factors for readmission were assessed: sex, age, diagnosis-related group, length of stay of initial hospitalization, type of hospitalization (conventional or day surgery), hospital volume activity, hospital volume for day surgery, and hospital status. Logistic regression multivariate analysis was used to assess risk factors.

RESULTS AND LIMITATIONS

Overall, 419 787 patients were included among whom 77 241 patients (18.40%) were readmitted within the following 30 d. After multivariate analyses, male sex (odds ratio [OR]=1.84, confidence interval [CI] 95%: 1.81-1.88), high level of comorbidity (diagnosis-related group 3-4 vs 1-2: OR=2.14, CI 95%: 2.10-2.21), and initial management in a private hospital (private vs university hospital: OR=1.13, CI 95%: 1.11-1.16; private vs public general hospital: OR=1.21, CI 95%: 1.18-1.23) were associated with a higher risk of readmission within 30 d.

CONCLUSIONS

Reported readmission rate within 30 d after a planned a urological procedure was nearly 20%.

PATIENT SUMMARY

In this French national study, we investigated the readmission rate within 30 d after a planned urological procedure in a large French population and discovered it was nearly 20%.

Hospital Ownership of a Postacute Care Facility Influences Discharge Destinations After Emergent Surgery

OBJECTIVE

The aim of the study was to identify hospital characteristics associated with variation in patient disposition after emergent surgery.

SUMMARY BACKGROUND DATA

Colon resections in elderly patients are often done in emergent settings. Although these operations are known to be riskier, there are limited data regarding postoperative discharge destination.

METHODS

We evaluated Medicare beneficiaries who underwent emergent colectomy between 2008 and 2010. Using hierarchical logistic regression, we estimated patient and hospital-level risk-adjusted rates of nonhome discharges. Hospitals were stratified into quintiles based on their nonhome discharge rates. Generalized linear models were used to identify hospital structural characteristics associated with nonhome discharges (comparing discharge to skilled nursing facilities vs home with/without home health services).

RESULTS

Of the 122,604 patients surviving to discharge after emergent colectomy at 3012 hospitals, 46.7% were discharged to a nonhome destination. There was a wide variation in risk and reliability-adjusted nonhome discharge rates across hospitals (15% to 80%). Patients at hospitals in the highest quintile of nonhome discharge rates were more likely to have longer hospitalizations (15.1 vs 13.2; P < 0.001) and more complications (43.2% vs 34%; P < 0.001). On multivariable analysis, only hospital ownership of a skilled nursing facility (P < 0.001), teaching status (P = 0.025), and low nurse-to-patient ratios (P = 0.002) were associated with nonhome discharges.

CONCLUSIONS

Nearly half of Medicare beneficiaries are discharged to a nonhome destination after emergent colectomy. Hospital ownership of a skilled nursing facility and low nurse-to-patient ratios are highly associated with nonhome discharges. This may signify the underlying financial incentives to preferentially utilize postacute care facilities under the traditional fee-for-service payment model.