Portal de Periódicos da CAPES

Association of surgery type and duration of hospitalisation with the ability to live independently after surgery

2021; Elsevier BV; Volume: 127; Issue: 3 Linguagem: Inglês

10.1016/j.bja.2021.06.007

1471-6771

Felix C. Linhardt, Luca J. Wachtendorf, Karuna Wongtangman, Omid Azimaraghi, Maximilian S. Schaefer, Matthias Eikermann, Samir Kendale,

Enhanced Recovery After Surgery

Editor—The loss of the ability to live independently after surgery is an undesirable endpoint that is dreaded by patients, relatives, and their healthcare providers.1Myles P.S. Shulman M.A. Heritier S. et al.Validation of days at home as an outcome measure after surgery: a prospective cohort study in Australia.BMJ Open. 2017; 7e015828Crossref PubMed Scopus (82) Google Scholar Patients who lived independently before surgery and required postoperative discharge to a nursing home often carry a long-term disability, and their healthcare costs are substantially increased.2Mohanty S. Liu Y. Paruch J.L. et al.Risk of discharge to postacute care: a patient-centered outcome for the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator.JAMA Surg. 2015; 150: 480-484Crossref PubMed Scopus (35) Google Scholar Identifying patients at high risk of adverse postoperative outcomes can help guide appropriate postoperative care.3Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The age of the surgical population is increasing year on year.4Fowler A.J. Abbott T.E.F. Prowle J. Pearse R.M. Age of patients undergoing surgery.Br J Surg. 2019; 106: 1012-1018Crossref PubMed Scopus (88) Google Scholar We have recently observed that older patients undergoing orthopaedic surgery have a numerically higher risk of losing the ability to live independently than patients of similar age who undergo non-orthopaedic surgical procedures.5Schaefer M.S. Hammer M. Platzbecker K. et al.What factors predict adverse discharge disposition in patients older than 60 years undergoing lower-extremity surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) risk score.Clin Orthop Relat Res. 2021; 479: 546-547Crossref PubMed Scopus (4) Google Scholar,6Hammer M. Althoff F.C. Platzbecker K. et al.Discharge prediction for patients undergoing inpatient surgery: development and validation of the DEPENDENSE score.Acta Anaesthesiol Scand. 2021; 65: 607-617Crossref PubMed Scopus (2) Google Scholar We hypothesised, based on data from a representative national dataset, that older patients undergoing orthopaedic surgery compared with patients undergoing non-orthopaedic surgery have a higher risk of loss of previous independent living. We also examined the interplay between orthopaedic vs non-orthopaedic surgery, hospital length of stay, and loss of the ability to live independently after surgery. After approval by the Committee on Clinical Investigations at Beth Israel Deaconess Medical Center in Boston, MA, USA (protocol number: 2021P00156), we analysed data from the National Hospital Discharge Survey (NHDS). We included patients >65 yr old undergoing invasive surgery as defined by the Agency for Healthcare Research and Quality (Supplementary material Section S1.1.). Patients who were admitted to the hospital from a skilled nursing facility were excluded. We first investigated whether hospital length of stay was associated with loss of the ability to live independently after surgery, defined as discharge to a long-term skilled nursing facility, or in-hospital death. Contingent on this association, we examined whether orthopaedic vs non-orthopaedic surgery modified the association of hospital length of stay and age with the risk of loss of the ability to live independently. A multivariable logistic regression model adjusted for patient characteristics, comorbidities, and insurance status was applied (Supplementary material Section S.1.3.). Differential associations of orthopaedic vs non-orthopaedic surgery were investigated by including an interaction term between hospital length of stay and the type of surgery into the logistic regression model. We used linear combinations between the main effect and the interaction term to calculate odds ratios for subgroups.7Schaefer M.S. Raub D. Xu X. et al.Association between propofol dose and 1-year mortality in patients with or without a diagnosis of solid cancer.Br J Anaesth. 2020; 124: 271-280Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Among 193 609 included patients, a total of 46 309 (23.9%) lost the ability to live independently after surgery. Additional characteristics and a study flow can be found in Supplementary Tables S1 and S2 and Figure S1. Patients undergoing orthopaedic surgery had a higher adjusted risk of loss of independent living (40.8%, 95% confidence interval [CI]: 40.3–41.2%) compared with non-orthopaedic (16.9%; CI: 16.7–17.0%). Compared with short hospital length of stay, moderate (5–8 days) and prolonged (>8 days) hospital length of stays were associated with a higher risk of postoperative loss of the ability to live independently (adjusted odds ratio [aOR]: 2.23; 95%; CI: 2.17–2.30; P<0.001 and 5.00; 95% CI: 4.84–5.17; P<0.001, respectively, Fig. 1). Orthopaedic surgery vs non-orthopaedic surgery mitigated the association of hospital length of stay and loss of the ability to live independently (aOR for long vs short hospital stays in orthopaedic patients: 3.00; CI: 2.87–3.13; vs 7.50; CI: 7.21–7.81 in non-orthopaedic patients; P for interaction <0.001). Sensitivity analyses were performed to verify these results (Supplementary material Section S2.1. and S2.2.). Our National data support results from hospital registries,2Mohanty S. Liu Y. Paruch J.L. et al.Risk of discharge to postacute care: a patient-centered outcome for the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator.JAMA Surg. 2015; 150: 480-484Crossref PubMed Scopus (35) Google Scholar,5Schaefer M.S. Hammer M. Platzbecker K. et al.What factors predict adverse discharge disposition in patients older than 60 years undergoing lower-extremity surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) risk score.Clin Orthop Relat Res. 2021; 479: 546-547Crossref PubMed Scopus (4) Google Scholar,6Hammer M. Althoff F.C. Platzbecker K. et al.Discharge prediction for patients undergoing inpatient surgery: development and validation of the DEPENDENSE score.Acta Anaesthesiol Scand. 2021; 65: 607-617Crossref PubMed Scopus (2) Google Scholar indicating that older patients undergoing orthopaedic surgery compared with patients undergoing non-orthopaedic surgery have a magnified risk of losing the ability to live independently. Long hospital length of stay was associated with additional risk, which further supports the validity of this important outcome indicator.8Haller G. Bampoe S. Cook T. et al.Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: clinical indicators.Br J Anaesth. 2019; 123: 228-237Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,9Moonesinghe S.R. Jackson A.I.R. Boney O. et al.Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: patient-centred outcomes.Br J Anaesth. 2019; 123: 664-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar A longer postoperative hospitalisation may allow for health status improvements, for example through physiotherapy, or medical treatment of postoperative anaemia, which decreases the risk of hospital readmission and might be specifically important after orthopaedic procedures.10Bisbe E. Basora M. Colomina M.J. Review peri-operative treatment of anaemia in major orthopaedic surgery: a practical approach from Spain.Blood Transfus. 2017; 15: 296-306PubMed Google Scholar However, we cannot conclude a cause-effect relation. An alternative explanation is that the association between hospital length of stay and loss of independence may be related to patients' frailty and comorbidity load, and procedural complexity and complications.5Schaefer M.S. Hammer M. Platzbecker K. et al.What factors predict adverse discharge disposition in patients older than 60 years undergoing lower-extremity surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) risk score.Clin Orthop Relat Res. 2021; 479: 546-547Crossref PubMed Scopus (4) Google Scholar,11Khan N.A. Quan H. Bugar J.M. Lemaire J.B. Brant R. Ghali W.A. Association of postoperative complications with hospital costs and length of stay in a tertiary care center.J Gen Intern Med. 2006; 21: 177-180Crossref PubMed Scopus (0) Google Scholar This study has several limitations related to the analysis of administrative databases. ICD-9 codes recorded in the NHDS database were used for retrieving medical information such as comorbidities and procedures and there might be potential coding errors owing to the extensive sample size. Additionally, the number of possible ICD-9 codes was restricted. The NHDS also methodologically fails to capture post-discharge events such as readmissions and post-discharge mortality. Older patients undergoing orthopaedic compared with non-orthopaedic surgery had a higher adjusted risk of losing previous independent living. In addition, longer hospital length of stay was associated with an increased risk of this outcome, but the association was modified towards less clinical significance in orthopaedic patients. Future studies should explore risks and opportunities of prolonged postoperative hospital length of stay in older patients, such as frailty.12McIsaac D.I. Taljaard M. Bryson G.L. et al.Frailty and long-term postoperative disability trajectories: a prospective multicentre cohort study.Br J Anaesth. 2020; 125: 704-711Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Study design: all authors Data analysis: FCL, LJW, OA, KW Interpretation of findings: all authors Writing and revising: all authors Guarantor of the study with responsibility for all parts from inception to publication: ME The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. ME has received grants for investigator-initiated trials not related to this manuscript from Merck & Co. and served as a consultant in the advisory board of Merck & Co. during the conduct of the study. The funders had no role in the study's design and conduct, the collection, management, analysis, and interpretation of the data, the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication. The other authors declare that they have no conflicts of interest. An unrestricted grant from Jeffrey and Judith Buzen (philanthropic donation; award number: 222302 ) to [ME].