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Original Investigation |

Postacute Care After Major Abdominal Surgery in Elderly Patients Intersection of Age, Functional Status, and Postoperative Complications

Courtney J. Balentine, MD, MPH1; Aanand D. Naik, MD2,3; David H. Berger, MD, MHCM3,4; Herbert Chen, MD5; Daniel A. Anaya, MD6; Gregory D. Kennedy, MD, PhD1
[+] Author Affiliations
1Department of Surgery, University of Wisconsin, Madison
2Alkek Department of Medicine, Baylor College of Medicine, Houston, Texas
3VA Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
4Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
5Department of Surgery, University of Alabama at Birmingham
6Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
JAMA Surg. 2016;151(8):759-766. doi:10.1001/jamasurg.2016.0717.
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Importance  Advanced age is an important risk factor for discharge to postacute care (PAC) facilities including skilled nursing and rehabilitation. Factors modifying the age-related risk of discharge to PAC have not been adequately examined for surgical patients.

Objective  To evaluate how preoperative functional status and postoperative complications affect age-related risk of discharge to PAC facilities following major abdominal surgery.

Design, Setting, and Participants  Retrospective cohort study of 55 238 patients aged 18 years or older having colorectal, pancreas, or liver operations in 2011 and 2012 at hospitals participating in the National Surgical Quality Improvement Program. Age was classified as younger than 65 years, 65 to 74 years, 75 to 84 years, and 85 years or older. The study was conducted between July 1, 2014, and July 1, 2015.

Main Outcomes and Measures  The primary outcome was discharge to a PAC facility following surgery. The secondary outcome was type of PAC facility (skilled nursing, rehabilitation, or other facility).

Results  Among 55 238 patients (mean [SD] age, 61 [15] years; 49% male) having colorectal, pancreas, or liver operations, 5325 (10%) were discharged to PAC facilities after major abdominal surgery. Skilled nursing facilities were the most common type of PAC (63%), followed by rehabilitation hospitals (30%) and other facilities (7%). Older age was an important predictor of discharge to PAC facilities, but there were significant interaction effects with age and postoperative complications. Among functionally independent patients who avoided postoperative complications, rates of discharge to PAC increased from 1% in the group younger than 65 years to 30% in the group aged 85 years or older. For functionally independent patients with multiple complications, 13% of patients younger than 65 years were discharged to PAC facilities compared with 66% of those aged 85 years or older. After risk adjustment, the oldest patients were 27 times more likely to be discharged to PAC than the youngest group when there were no postoperative complications (odds ratio = 26.6; 95% CI, 21.6-32.7) and 11 times more likely after multiple complications (odds ratio = 11.4; 95% CI, 8.3-15.6). Among functionally dependent patients, the overall risk of discharge to PAC facilities was increased, but age was not as important a predictor for discharge to PAC.

Conclusions and Relevance  Older patients are frequently discharged to PAC facilities even when they are functionally independent and without postoperative complications. Helping older patients to return home after surgery and avoid placement in PAC facilities will require innovative programs that go beyond reducing complication rates and enhance postoperative recovery.

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Figure 1.
Percentage of Patients Discharged to Postacute Care (PAC) Facilities According to Age, Number of Postoperative Complications, and Functional Status
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Figure 2.
Percentage Discharged to Each Postacute Care (PAC) Setting for Functionally Independent and Dependent Patients by Number of Postoperative Complications
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Figure 3.
Univariable and Multivariable Estimates for Odds Ratio (OR) of Discharge to Postacute Care (PAC) Facility According to Patient Age, Number of Postoperative Complications, and Functional Status
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