Discharge to Institution Tied to Mortality Risk

CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.

Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients versus 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.

“Elderly patients often have functional decline following major surgery. But there is a lack of outcomes [information] on those who require postdischarge care,” Dr. Wiktor said.

He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.

A total 29 of the 167 patients (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, Dr. Wiktor said.

Operative time and blood loss did not differ significantly between patients transferred to a facility and those discharged to home. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group, and mean blood loss was 561 mL versus 603 mL, respectively.

Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years versus 64 years), had a longer ICU stay (11 days versus 6 days), and had a longer overall hospital stay (20 days versus 9 days) than those discharged to home.

“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said. Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. The admitted patients had a mean score of 2.6 versus 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients versus 97.4 in those discharged to home, as measured on the Barthel Index scale. The researchers also found a significant difference in comorbidities on the Charlson Index: 4.9 in the admitted group versus 2.6 in the discharged group.

Dr. Martin A. Makary, a study discussant, asked why the investigators chose to assess patients 50 years and older for an “elderly” study.

Dr. Wiktor replied, “That is why we chose such a wide age group and started at 50. We didn't want to short-change ourselves if we saw a trend earlier versus later.”

Could the age disparity be explained by older patients undergoing more complex procedures? asked Dr. Makary, the Mark Ravitch Chair of Gastrointestinal Surgery and director of the Johns Hopkins Center for Surgical Outcomes in Baltimore.

Complexity was not likely a factor, Dr. Wiktor replied, because the investigators anticipated that all participants would be admitted to critical care after their elective surgery.

“Surprising to me was that four out of five of your elderly patients went home after major surgery,” said Dr. Hasan Badre Alam, a comoderator of the session. He commented that none of the risk factors identified are modifiable.

“It would be useful to identify risk factors that distinguish the 24% who are going to die [by 6 months] versus the 76% who will not,” said Dr. Alam, a staff surgeon at Massachusetts General Hospital, Boston.

“That is why this research is so interesting and sometimes frustrating,” Dr. Wiktor replied. “Patients come with comorbidities, and sometimes there is little you can do. But having a frank discussion with these patients before surgery may lead to them making small changes.”

My Take

Stratify Risks to Improve Outcomes

Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.

It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.

The more precisely we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.

Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients versus 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.

“Elderly patients often have functional decline following major surgery. But there is a lack of outcomes [information] on those who require postdischarge care,” Dr. Wiktor said.

He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.

A total 29 of the 167 patients (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, Dr. Wiktor said.

Operative time and blood loss did not differ significantly between patients transferred to a facility and those discharged to home. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group, and mean blood loss was 561 mL versus 603 mL, respectively.

Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years versus 64 years), had a longer ICU stay (11 days versus 6 days), and had a longer overall hospital stay (20 days versus 9 days) than those discharged to home.

“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said. Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. The admitted patients had a mean score of 2.6 versus 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients versus 97.4 in those discharged to home, as measured on the Barthel Index scale. The researchers also found a significant difference in comorbidities on the Charlson Index: 4.9 in the admitted group versus 2.6 in the discharged group.

Dr. Martin A. Makary, a study discussant, asked why the investigators chose to assess patients 50 years and older for an “elderly” study.

Dr. Wiktor replied, “That is why we chose such a wide age group and started at 50. We didn't want to short-change ourselves if we saw a trend earlier versus later.”

Could the age disparity be explained by older patients undergoing more complex procedures? asked Dr. Makary, the Mark Ravitch Chair of Gastrointestinal Surgery and director of the Johns Hopkins Center for Surgical Outcomes in Baltimore.

Complexity was not likely a factor, Dr. Wiktor replied, because the investigators anticipated that all participants would be admitted to critical care after their elective surgery.

“Surprising to me was that four out of five of your elderly patients went home after major surgery,” said Dr. Hasan Badre Alam, a comoderator of the session. He commented that none of the risk factors identified are modifiable.

“It would be useful to identify risk factors that distinguish the 24% who are going to die [by 6 months] versus the 76% who will not,” said Dr. Alam, a staff surgeon at Massachusetts General Hospital, Boston.

“That is why this research is so interesting and sometimes frustrating,” Dr. Wiktor replied. “Patients come with comorbidities, and sometimes there is little you can do. But having a frank discussion with these patients before surgery may lead to them making small changes.”

My Take

Stratify Risks to Improve Outcomes

Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.

It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.

The more precisely we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.

Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients versus 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.

“Elderly patients often have functional decline following major surgery. But there is a lack of outcomes [information] on those who require postdischarge care,” Dr. Wiktor said.

He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.

A total 29 of the 167 patients (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, Dr. Wiktor said.

Operative time and blood loss did not differ significantly between patients transferred to a facility and those discharged to home. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group, and mean blood loss was 561 mL versus 603 mL, respectively.

Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years versus 64 years), had a longer ICU stay (11 days versus 6 days), and had a longer overall hospital stay (20 days versus 9 days) than those discharged to home.

“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said. Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. The admitted patients had a mean score of 2.6 versus 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients versus 97.4 in those discharged to home, as measured on the Barthel Index scale. The researchers also found a significant difference in comorbidities on the Charlson Index: 4.9 in the admitted group versus 2.6 in the discharged group.

Dr. Martin A. Makary, a study discussant, asked why the investigators chose to assess patients 50 years and older for an “elderly” study.

Dr. Wiktor replied, “That is why we chose such a wide age group and started at 50. We didn't want to short-change ourselves if we saw a trend earlier versus later.”

Could the age disparity be explained by older patients undergoing more complex procedures? asked Dr. Makary, the Mark Ravitch Chair of Gastrointestinal Surgery and director of the Johns Hopkins Center for Surgical Outcomes in Baltimore.

Complexity was not likely a factor, Dr. Wiktor replied, because the investigators anticipated that all participants would be admitted to critical care after their elective surgery.

“Surprising to me was that four out of five of your elderly patients went home after major surgery,” said Dr. Hasan Badre Alam, a comoderator of the session. He commented that none of the risk factors identified are modifiable.

“It would be useful to identify risk factors that distinguish the 24% who are going to die [by 6 months] versus the 76% who will not,” said Dr. Alam, a staff surgeon at Massachusetts General Hospital, Boston.

“That is why this research is so interesting and sometimes frustrating,” Dr. Wiktor replied. “Patients come with comorbidities, and sometimes there is little you can do. But having a frank discussion with these patients before surgery may lead to them making small changes.”

My Take

Stratify Risks to Improve Outcomes

Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.

It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.

The more precisely we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.