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Healthy Days at Home after Emergency General Surgery: Shifting Towards Long-Term Patient-Centered Outcomes for Older Adults
Manuel Castillo-Angeles
*1, Cheryl K. Zogg
2, Lingwei Xiang
1, Rachel Adler
1, Alexander Ordoobadi
1, Emily Finlayson
3, Dae Kim
7, John Hsu
4, Samir Shah
5, Clancy Clark
6, Joel Weissman
1, Joaquim M. Havens
11Surgery, Brigham and Women's Hospital, Boston, MA; 2Duke University Medical Center, Durham, NC; 3University of California San Francisco, San Francisco, CA; 4Massachusetts General Hospital, Boston, MA; 5Surgery, University of Florida, Gainesville, FL; 6Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC; 7Beth Israel Deaconess Medical Center, Boston, MA
Background: The presence of multiple comorbidities, frailty, dementia, and physiologic vulnerability makes emergency general surgery (EGS) a unique challenge for older adults. The current literature often lacks assessments of measures relevant to patients and caregivers such as the amount of time spent at home. The number of post-operative days at home (HDAH) has emerged as a reliable marker of patient functional status with a prognostic value in surgical care. Our goal was to determine the correlates of HDAH after EGS in older adults, and to assess if these variables varied by procedural risk level.
Study Design: Using 2017 100% Medicare fee-for-service claims, we identified community-dwelling older adults, 65 years or older, who underwent an EGS procedure, stratified into high-risk (excision of small or large intestine, peptic ulcer repair, lysis of peritoneal adhesions, laparotomy) and low-risk procedures (appendectomy, cholecystectomy). HDAH were calculated from the date of discharge up to one year, minus any time spent in the hospital or emergency department, rehabilitation/nursing/hospice facility, home health care, or after death after index admission. Multivariable regression analyses were performed to identify the factors associated with HDAH, stratified by procedural risk level.
Results: A total of 78,173 community-dwelling older adults were included; 39.5% (n=30,886) had a high-risk EGS procedure. HDAH were significantly lower after a high-risk procedure (mean 288.12 [113.11] vs. 329.81 [SD 77.48] days, p<0.001) compared to low-risk procedures, primarily driven by increased needs for skilled nursing facility (mean difference [95%CI]: +2.65[2.42-2.88] days) and home health agency (+9.96[9.43-10.48] days) care. Within high-risk procedures, predictors of HDAH included female sex (Coef. -6.59, 95% CI -8.94 to -4.24), Black race (Coef. -14.09, 95% CI -18.58 to -9.60), diagnosis of dementia before surgery (Coef. -19.61, 95% CI -24.01 to -15.21), and frailty (Coef. -120.48, 95% CI -128.02 to -112.94). Even though predictors of HDAH were similar within low-risk procedures, dementia had a stronger association with HDAH (Coef. -33.22, 95% CI -35.90 to -30.53).
Conclusions: High-risk EGS procedures led to an average of 1.5 months fewer HDAH in older adults. The impact of dementia on HDAH resulted in a greater reduction in HDAH after low-risk procedures than it did after high-risk procedures. Surgeons and geriatricians could use these predictors of HDAH when counseling patients about their expected post-operative course. HDAH is a robust valuable metric that can lead to the development of strategies tailored to the unique needs of this vulnerable population.
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