Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study

Abstract

BACKGROUND: Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN: Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS: Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS: Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions

“…We included only patients with early operations to minimize the effects of the hospital course on treatment outcomes, and defined operative management as the receipt of surgery within 2 days of admission, per custom among prior publications within EGS 8,23,24 . Multimorbidity was defined by the presence of a qualifying comorbidity set (QCS) 25,26 . When patients have many medical problems, these comorbidities have the potential to interact, influencing a patient’s overall health, and adding complexity to studying this patient population, which limits evidence-based clinical decision support for such patients 27–29 .…”

“…8,23,24 Multimorbidity was defined by the presence of a qualifying comorbidity set (QCS). 25,26 When patients have many medical problems, these comorbidities have the potential to interact, influencing a patient's overall health, and adding complexity to studying this patient population, which limits evidence-based clinical decision support for such patients. [27][28][29] QCSs, developed by Silber et al, 25 consider these interactions and have been shown to outperform other measures of multimorbidity.…”

“…[27][28][29] QCSs, developed by Silber et al, 25 consider these interactions and have been shown to outperform other measures of multimorbidity. 20,25,26…”

A Novel Mobile App to Identify Patients With Multimorbidity in the Emergency Setting: Development of an App and Feasibility Trial

“…In this spirit, in 2018, Silber et al [5] proposed Qualifying Comorbidity Sets as a comprehensive mechanism to account for these interactions and identify multimorbidity among surgical patients when using discharge claims data. Our previous work has found this definition of multimorbidity to offer greater selectivity and to be associated with the greater risk of poor outcomes than other count-based definitions [11,12]. Clinical operationalization of this definition, however, is limited due to (1) the difficulty in recognizing that a Qualifying Comorbidity Set may be present for an individual patient and (2) the claims-based nature of the definition.…”

The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients

“…3,4 Among the high-risk patients that EGS providers treat, older adults (≥65 years) represent a unique population-one often faced with increased risk of adverse outcomes owing to factors related to age (e.g., frailty, preexisting multimorbidity) that put older EGS patients at increased risk for mortality during the perioperative period (e.g., death within 30 days) and over the subsequent course of prolonged recovery (e.g., death within 365 days). Research published over the last 10 years to 20 years has shown consistently strong relationships between factors related to age, [5][6][7][8][9] frailty, [10][11][12][13][14] and a patient's extent of multimorbidity [15][16][17][18][19][20] that affect both shortand long-term mortality among all EGS patients. 10,11 Emerging research in recent years has expanded these efforts to further explore how variations in where patients live can influence differences in baseline EGS mortality risk.…”