Discharge Prediction for Patients Undergoing Inpatient Surgery: Development and validation of the DEPENDENSE score

Abstract

BackgroundA substantial proportion of patients undergoing inpatient surgery each year is at risk for postoperative institutionalization and loss of independence. Reliable individualized preoperative prediction of adverse discharge can facilitate advanced care planning and shared decision making.MethodsUsing hospital registry data from previously home‐dwelling adults undergoing inpatient surgery, we retrospectively developed and externally validated a score predicting adverse discharge. Multivariable logistic regression analysis and bootstrapping were used to develop the score. Adverse discharge was defined as in‐hospital mortality or discharge to a skilled nursing facility. The model was subsequently externally validated in a cohort of patients from an independent hospital.ResultsIn total, 106 164 patients in the development cohort and 92 962 patients in the validation cohort were included, of which 16 624 (15.7%) and 7717 (8.3%) patients experienced adverse discharge, respectively. The model was predictive of adverse discharge with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI 0.87‐0.88) in the development cohort and an AUC of 0.86 (95% CI 0.86‐0.87) in the validation cohort.ConclusionUsing preoperatively available data, we developed and validated a prediction instrument for adverse discharge following inpatient surgery. Reliable prediction of this patient centered outcome can facilitate individualized operative planning to maximize value of care.

Association of surgery type and duration of hospitalisation with the ability to live independently after surgery

“…Our National data support results from hospital registries, 2,5,6 indicating that older patients undergoing orthopaedic surgery compared with patients undergoing nonorthopaedic surgery have a magnified risk of losing the ability to live independently. Long hospital length of stay was associated with additional risk, which further supports the validity of this important outcome indicator.…”

“…Although more patients in the liberal group had gastric fluid volumes >1.5 ml kg À1 , this is reasonably in line with previous studies that measured gastric fluid volumes in standard fasted adults: 3e6% of patients had volumes >1.5 ml kg À1 . 6 In one study, 21% of standard fasted patients had gastric volume >1.5 ml kg À1 . 8 In a study that randomised children into standard or liberal fluid fasting policy, 1% of children in the standard group had gastric fluid volume >2 ml kg À1 vs 15% in the liberal group, a significant difference.…”

“…4 We have recently observed that older patients undergoing orthopaedic surgery have a numerically higher risk of the ability to live independently than patients of similar age who undergo non-orthopaedic surgical procedures. 5,6 We hypothesised, based on data from a representative national dataset, that older patients undergoing orthopaedic surgery compared with patients undergoing non-orthopaedic surgery have a higher risk of loss of previous independent living. We also examined the interplay between orthopaedic vs nonorthopaedic surgery, hospital length of stay, and loss of the ability to live independently after surgery.…”

Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home

“…To confirm the robustness of our primary findings, we conducted several sensitivity analyses, including reevaluation of the primary analysis in a cohort following multiple imputation and after propensity score matching as well as in stratification analyses by insurance status, estimated household income, and anesthesia type. Further we tested the generalizability of our findings in subgroups of patients with different case acuities as well as across patients with a high versus low risk of postoperative discharge to a nursing home based on a previously published risk score 11. Lastly, we performed additional confounding adjustment and compared the racial distribution of our dataset to the Massachusetts Cancer Registry 25.…”

“…Further we tested the generalizability of our findings in subgroups of patients with different case acuities as well as across patients with a high versus low risk of postoperative discharge to a nursing home based on a previously published risk score. 11 Lastly, we performed additional confounding adjustment and compared the racial distribution of our dataset to the Massachusetts Cancer Registry. 25 Details are provided in Supplement 1, Section S5, http://links.lww.com/ SLA/D992.…”