Loss of Community‐Dwelling Status Among Survivors of High‐Acuity Emergency General Surgery Disease

Abstract

OBJECTIVES To examine loss of community‐dwelling status 9 months after hospitalization for high‐acuity emergency general surgery (HA‐EGS) disease among older Americans. DESIGN Retrospective analysis of claims data. SETTING US communities with Medicare beneficiaries. PARTICIPANTS Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra‐abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319). MEASUREMENTS Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long‐term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community‐dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan‐Meier plots, and χ2 tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community‐dwelling status at 9 months. RESULTS A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in‐hospital complications. Overall, 418 (14.3%) HA‐EGS survivors died during the follow‐up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA‐EGS. CONCLUSION Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA‐EGS. Long‐term expectations after surviving HA‐EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality‐of‐life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289–2297, 2019

Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore

“… 16 As a large proportion of EL patients are elderly, postoperative geriatric assessment and care should receive more attention, in a manner analogous to orthogeriatric care in patients with hip fractures. 17 In the first 4 years that NELA data were collected, improvements in 30‐ and 90‐day mortality were most apparent in the oldest cohort of NELA patients. 18 On the same note, introduction of the ELAP pathway was associated with reduction in 30‐day mortality in the elderly.…”

“…Elderly patients are more likely to have age‐related physiological impairment and exhibit frailty, sarcopenia, and functional and cognitive impairment 16 . As a large proportion of EL patients are elderly, postoperative geriatric assessment and care should receive more attention, in a manner analogous to orthogeriatric care in patients with hip fractures 17 . In the first 4 years that NELA data were collected, improvements in 30‐ and 90‐day mortality were most apparent in the oldest cohort of NELA patients 18 .…”

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States

“…In agreement with other studies evaluating predictive factors for patients diagnosed with an EGS condition undergoing surgical intervention, our study found that as age increased, so did the likelihood for being discharged to a facility for supplementary care. 10 An additional factor indicating likelihood that a facility would be needed at time of discharge was having more than two comorbidities before admission. As mentioned previously, as age increases, the likelihood for comorbidities being present also increases.…”

“…Owing to the rarity of this disease, approximately 2% incidence in one study, and the significant impact NSTIs cause on quality of life, a study assessing only this patient population is warranted, as very little has been reported in older adults. 10 NSTIs are rapidly progressing, life-threatening diseases, characterized by both inflammation and necrosis of subcutaneous fat, fascia, or muscle. 11 Despite advances in surgical and anti-infective therapy, NSTIs continue to have a significant mortality rate, with some studies reporting ranges from 24 to 34%.…”

Narrative review of palliative care in trauma and emergency general surgery

“…In the year after surgery, older adults have a 30% 1-year mortality and high rates of healthcare utilization, suggesting that even patients who survive the initial hospitalization are extremely vulnerable. Among those who survive, one in 10 older Americans who were community-dwelling transfer to a nursing facility or long-term acute care facility by nine months postoperatively ( 42 ). Again, the “surprise question” is a simple and useful tool to screen patients for palliative care needs to identify patients with a high risk of death.…”