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Original Investigation | Pacific Coast Surgical Association

Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures Online Only

Julia R. Berian, MD1,2; Sanjay Mohanty, MD, MS1,3; Clifford Y. Ko, MD, MS, MSHS1,4; Ronnie A. Rosenthal, MS, MD5; Thomas N. Robinson, MD, MS6
[+] Author Affiliations
1Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
2Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
3Department of Surgery, Henry Ford Health System, Detroit, Michigan
4Department of Surgery, University of California, Los Angeles
5Department of Surgery, Yale University, New Haven, Connecticut
6Department of Surgery, University of Colorado-Denver, Aurora
JAMA Surg. 2016;151(9):e161689. doi:10.1001/jamasurg.2016.1689.
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Importance  Older adults are at increased risk for adverse events after surgical procedures. Loss of independence (LOI), defined as a decline in function or mobility, increased care needs at home, or discharge to a nonhome destination, is an important patient-centered outcome measure.

Objective  To evaluate LOI among older adult patients after surgical procedures and examine the association of LOI with readmission and death after discharge in this population.

Design, Setting, and Participants  This retrospective cohort study examined 9972 patients 65 years and older with known baseline function, mobility, and living situation undergoing inpatient operations from January 2014 to December 2014 at 26 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project. A total of 4895 patients were excluded because they were totally dependent, classified as class 5 by the American Society of Anesthesiologists, undergoing orthopedic or spinal procedures, or died prior to discharge.

Exposures  Loss of independence at time of discharge.

Main Outcomes and Measures  Readmission and death after discharge.

Results  Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge.

Conclusions and Relevance  Loss of independence, a patient-centered outcome, was associated with postoperative readmissions and death after discharge. Loss of independence can feasibly be collected across multiple hospitals in a national registry. Clinical initiatives to minimize LOI will be important for improving surgical care for older adults.

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Loss of Independence

All categories measured at time of discharge. A, There were 1348 patients (26.6%) who experienced decreased function, 1626 (32.0%) with decreased mobility, 1414 (27.8%) discharged to home with new care needs, and 925 (18.2%) discharged to a nonhome destination. B, There were 2050 patients (40.0%) with no loss of independence, 1407 (27.7%) with worsening in 1 category, 954 (18.8%) with worsening in 2 categories, and 666 (13.1%) with worsening in all 3 categories (decreased function and mobility and increased care needs). Decreased function indicates patients who were independent or partially dependent before the surgical procedure who became partially or totally dependent after. Decreased mobility indicates patients who were discharged with a new mobility aid not present at the time of admission. Increased care needs indicates patients who were discharged home requiring new services or support in the home or who were discharged to a nonhome destination (eg, rehabilitation or skilled or unskilled nursing facilities).

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