Loss of Independence is associated with readmission and delayed death in older surgical patients

Loss of Independence is associated with readmission and delayed death in older surgical patients @BerianJulia July 18, 2016 ACS NSQIP 2016 Annual Meeting Julia R. Berian MD,MS; Clifford Y. Ko MD,MS,MSHS; Sanjay Mohanty MD,MS; Ronnie A. Rosenthal MS,MD; Thomas N. Robinson MD,MS

Disclosures 2015-2017 James C. Thompson Fellowship position supported by the John A. Hartford Foundation

Aging population Roughly 10,000 adults turned 65 today The same tomorrow x19 years Ref: Pew Research Center population projections

Aging population Disproportionate share of surgical procedures: 38% or 19.2 million procedures CDC NHDS 2010 Different priorities: 75-89% would forgo lifesaving treatment if it meant severe functional and cognitive impairment Fried et al. 2002 NEJM

Data Source Priority outcomes for older adults Function Cognition Mobility Aims: (1) Evaluate a novel composite measure loss of independence and (2) its association with readmission and delayed death among older surgical patients.

Loss of Independence Home Admission Operation Discharge Back to living independently?

Loss of Independence 1. Decline in Function (Activities of daily living) 2. Decline in Mobility (New equipment) 3. New care needs on discharge (Environment)

1. Decline in Function Pre-Op Independent Post-Op Independent Partially Dependent Partially Dependent Dependent

2. Decline in Mobility

3. New care needs on discharge Home Return Home Home with new services DC to Facility

Loss of Independence Loss of independence (LOI) Home Admission Operation Discharge Readmission? Death? 30 days No LOI

NSQIP Geriatric Surgery Pilot Project Inclusion: Older adults aged 65 and older Undergoing inpatient operation in one of 26 hospitals participating in the Geriatric Surgery Pilot January December 2014 Exclusion: Total dependence / moribund Orthopedic / spinal procedures Death before discharge Missing data: multiple imputation >5% Fall history, missing 12% Preop cognitive impairment, 9%

Sample characteristics N = 5077 older adults Age 75±7 years 2736 female (53.9%) Surgical interventions: General surgery n=2934 (58%) Vascular surgery n=965 (19%) Urologic and gynecologic surgery n=622 (12%) Other surgical specialties (11%)

Function, Mobility, Care Needs 50% Percentage of patients with specified decline 45% 40% 35% 30% 25% 20% 15% 10% 5% 1348 (26.6%) 1626 (32.0%) 1414 (27.8%) 925 (18.2%) Home with new care needs DC to nonhome facility Mobility decline Functional decline 0% Functional decline Mobility decline Increased care needs

Loss of Independence is frequent Percentage of patients with specified losses 100% 90% 80% 70% 60% 50% 40% 30% 20% N=3027 (59.6%) 666 (13%) 954 (18.8%) 1407 (27.7%) 2050 (40.4%) Major loss, decline in function, mobility and homecare needs Moderate loss, decline in two categories Minor loss, decline in one category No loss of independence 10% 0% Older adult surgical patients

LOI increases with age 100.00% Percentage of patients experiencing LOI 80.00% 60.00% 40.00% 20.00% 0.00% 1386 (49.9%) 1162 (67.3%) 479 (83.9%) 65-74 75-84 85+ Age in years P <.001

Older, Sicker patients experience LOI Patient Characteristics N (%) No LOI N = 2050 LOI N = 3027 Age 65-74 1394 (68) 1386 (46) 75-84 564 (28) 1162(38) 85+ 92 (5) 479 (16) Female 1040(51) 1696 (56) ASA Class I & II 762 (37) 519(17) III & IV 1288 (63) 2508 (83) Smoke 205 (10) 417 (14) Fall within 1 year 144 (7) 605 (20) Unintentional Weight Loss (10% body weight in prior 6 months) 47 (2) 173 (6) Preoperative cognitive impairment 136 (7) 372 (12) Consent signed by surrogate 32 (2) 203 (7) Emergency operation 122 (6) 448 (15) Significant at P<.001

LOI and readmissions Readmission rate: n = 517 (10.2%) Multivariable logistic regression with forward selection, risk factors available included: Loss of Independence Age Sex BMI ASA Class Smoking status Unintentional weight loss Fall history Preop living situation Preop cognitive impairment Need for surrogate consent Serious postop complication Emergency operation

LOI is associated with Readmission Characteristic OR 95% CI Postoperative complication 6.7 (4.9, 9.0) Loss of independence 1.7 (1.4, 2.2) Preop living situation Home alone Ref - Lives with support in the home 1.4 (1.1, 1.7) Non-home facility 1.3 (0.7, 2.1) ASA class I-II Ref - III-IV 1.5 (1.2, 1.8)

LOI and death after discharge Death after discharge: n=69 (1.1%) Multivariable logistic regression with forward selection, risk factors available included: Loss of Independence Age Emergency operation Unintentional weight loss Need for surrogate consent Preop cognitive impairment Fall history Serious postop complications

LOI is associated with Death after DC Characteristic Odds Ratio 95% CI Loss of independence 6.7 (2.4, 19.3) Surrogate Consent 6.0 (3.4, 10.5) Emergency operation 2.0 (1.2, 3.4) Age 65-74 Ref - 75-84 1.9 (1.1, 3.6) 85+ 2.4 (1.2, 4.8)

Limitations Retrospective database study Subset of NSQIP hospitals Short time frame (30 days)

Findings Over half of older patients experience some degree of loss of independence Mobility Function Living situation LOI is strongly associated with increased risks for: Readmission (70% increase) Death after discharge (6.7-fold)

Conclusions Change in care pathways Mobility and function preservation Recruitment of social support May improve readmission rates and potentially death after discharge

Acknowledgements Marcus Escobedo Clifford Y. KoMD,MS,MSHA Thomas N Robinson MD,MS Ronnie A. Rosenthal MD,MS Karl Y. Bilimoria MD,MS Jeffrey B. Matthews, MD Mitchell C. Posner, MD Kevin K. Roggin, MD