Early Postoperative Functional Assessment Predicts Non-Home Discharge After Pulmonary Lobectomy

Normalized total psoas area predicts early postoperative mobility and perioperative adverse events after adult spinal deformity surgery

BACKGROUND CONTEXT

Poor muscle health has been shown to predict poor perioperative outcomes following adult spinal deformity (ASD) surgery. Currently, there is limited data concerning the correlation between muscle health and recovery among patients undergoing ASD surgery.

PURPOSE

To determine the relationship between normalized total psoas area (NTPA), postoperative mobility and adverse events (AEs) among patients undergoing ASD surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

A retrospective analysis was performed at a single institution between January 2014 and December 2023 of patients undergoing ASD surgery by 10 board certified fellowship-trained orthopaedic spine surgeons.

OUTCOME MEASURES

Primary outcome measures were postoperative ambulation distance on postoperative day (POD) 1, 2, 3, and 4 as well as perioperative adverse events including postoperative anemia requiring transfusion, ileus, urinary retention wound complication including dehiscence and infection, delirium, atelectasis, urinary tract infection (UTI), deep vein thrombosis (DVT), and epidural hematoma. Secondary outcome measures were 30-day reoperation rates, 30-day readmission rates, and postoperative length of stay (LOS).

METHODS

Patients that underwent ASD surgery at a single center (2014-2023) were included in the study. NTPA was analyzed at the L3 and L4 midvertebral body on preoperative magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was used to determine gender-specific NTPA cut-off values for predicting perioperative AEs. Patients were categorized as having a low NTPA if both L3 and L4 NTPA were below the cut-off values. Multivariate logistic regression was conducted to identify confounding predictors of perioperative AEs.

RESULTS

279 patients (102 males, 177 females, mean age 61.2±15.2 years) were included. ROC curve analysis demonstrated L3 NTPA <805 mm2/m2 for males and <505 mm2/m2 for females and L4 NTPA <912 mm2/m2 for males and <714 mm2/m2 for females as cut-off values predicting perioperative AEs. 103 patients (36.9%, 42 males, 61 females) were below these cut-off values and were in the low NTPA cohort. The remaining 176 patients (63.1%, 60 males, 116 females) were in the normal NTPA cohort. The low NTPA group had a higher overall perioperative AEs (70.9% vs 39.2%, p<.001), and lower ambulation distances on postoperative day 1 and 2 compared to the normal NTPA group (p=.021, p=.028, respectively). On multivariate analysis, there were no other predictors of perioperative AEs.

CONCLUSIONS

Low L3 and L4 NTPA is associated with lower early postoperative mobility and higher rates of perioperative AEs among patients undergoing ASD surgery. These findings stress the importance of muscle health in recovery after ASD surgery.

Patient-led walking program before lung resection: a pilot study on feasibility and impact on quality of life

BACKGROUND

The role of preoperative conditioning on postoperative outcomes in thoracic surgery is of growing interest. There is a paucity of data on understanding compliance with a patient-led walking program and its impact on quality of life.

OBJECTIVES

To understand the feasibility of patient-driven data collection of daily steps via pedometers and to understand the impact of preoperative conditioning on quality of life.

DESIGN

A prospective single-institution quality improvement study.

METHODS

The study included patients who underwent thoracic surgery between 2020 and 2022 who were and were selected to receive a pedometer at their preoperative clinic appointment. A daily step goal was determined, and patients were instructed to record their daily steps. Quality of life was assessed at baseline and at presentation for surgery. Clinical data and postoperative outcomes were derived from the institutional Society of Thoracic Surgery General Thoracic Surgery Database.

RESULTS

There were 167 patients provided with pedometers at their presurgical clinic appointment, of whom 43 returned pedometer data (utilization rate 26%). Of the 104 who underwent lung resection, 74 (44.3%) did not record step data, 15 had <6000 median daily steps, and 15 had >6000 median daily steps. Pre-intervention self-perceived outcomes were similar. Post-pedometer data demonstrated higher scores in the domains of general health (p = 0.016), quality of life (p = 0.03), general physical health (p = 0.002), physical performance (p = 0.03), social health (p = 0.009), social performance (p=0.01), and fatigue level (p = 0.01) for patients with higher median step counts. There were no significant differences in postoperative outcomes based on survival, length of stay (p = 0.77), or respiratory complications (p = 0.52).

CONCLUSION

A patient-led walking program using pedometers is feasible for a minority of patients. Higher recorded daily step counts are associated with improved self-perceived quality of life in patients prior to lung surgery.

Prehabilitation for Older Adults Undergoing Lung Cancer Surgery: A Literature Review and Needs Assessment

Early-stage lung cancer patients are increasingly considered for preoperative systemic therapy. Older adults in particular are among the most vulnerable patients, with little known on how preoperative therapies affect the risk-benefit of surgery. We sought to summarize the current literature and elucidate existing evidence gaps on the effects of prehabilitation interventions relative to age-related functional impairments and the unique needs of older patients undergoing lung cancer surgery. A literature review was performed using PubMed and Google Scholar databases, of all scientific articles published through April 2022 which report on the effects of prehabilitation on patients undergoing lung cancer surgery. We extracted current prehabilitation protocols and their impact on physical functioning, resilience, and patient-reported outcomes of older patients. Emerging evidence suggests that prehabilitation may enhance functional capacity and minimize the untoward effects of surgery for patients following lung resection similar to, or potentially even better than, traditional postoperative rehabilitation. The impact of preoperative interventions on surgical risk due to frailty remains ill-defined. Most studies evaluating prehabilitation include older patients, but few studies report on activities of daily living, self-care, mobility activities, and psychological resilience in older individuals. Preliminary data suggest the feasibility of physical therapy and resilience interventions in older individuals concurrent with systemic therapy. Future research is needed to determine best prehabilitation strategies for older lung cancer patients aimed to optimize age-related impairments and minimize surgical risk.

Predicting Non-home Discharge After Lung Surgery: Analysis of the General Thoracic Surgery Database

BACKGROUND

Anticipating the need for non-home discharge (NHD) enables improved patient counseling and expedites placement, potentially reducing length of stay and hospital readmission. The objective of this study was to create a simple, preoperative, clinical prediction tool for NHD using The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD).

METHODS

The STS GTSD was queried for patients who underwent elective anatomic lung cancer resection between 2009 and 2019. Exclusion criteria included age <18 years, percentage predicted diffusion capacity of the lung for carbon monoxide <20% or >150%, N3 or M1 disease, incomplete datasets, and mortality. The primary outcome was defined as discharge to an extended care, transitional care, rehabilitation center, or another hospital. Multivariable logistic regression was used to select risk factors and a nomogram for predicting risk of NHD was developed. The approach was cross-validated in 100 replications of a training set consisting of randomly selected two-thirds of the cohort and a validation set of remaining patients.

RESULTS

A total of 35 948 patients from the STS GTSD met inclusion criteria. Final model variables used to derive the nomogram for NHD risk prediction included age (P < .001), percentage predicted diffusion capacity of the lung for carbon monoxide (P < .001), open surgery (P < .001), cerebrovascular history (P < .001), and Zubrod score (P < .001). The receiver operating characteristic curve, using sensitivities and specificities of the model, yielded area under the curve of 0.74. In 100 replicated cross-validations, out-of-sample area under the curve ranged from 0.72-0.76.

CONCLUSIONS

Using readily available preoperative variables, our nomogram prognosticates the risk of NHD after anatomic lung resection with good discriminatory ability. Such risk stratification can enable improved patient counseling and facilitate better planning of patients' postoperative needs.

Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery

BACKGROUND CONTEXT

Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients.

PURPOSE

To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery.

DESIGN

Retrospective review.

PATIENT SAMPLE

Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained.

OUTCOME MEASURES

The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute.

METHODS

Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM.

RESULTS

LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM.

CONCLUSIONS

Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery.

LEVEL OF EVIDENCE

III.

AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery

BACKGROUND CONTEXT

Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery.

PURPOSE

To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery.

STUDY DESIGN

Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included.

OUTCOME MEASURES

Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold.

RESULTS

Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge.

CONCLUSIONS

First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.

The Predictive Validity of Functional Outcome Measures With Discharge Destination for Hospitalized Medical Patients

Objective

To investigate the predictive validity for discharge to home or facility of 4 functional mobility outcome measures.

Design

Retrospective, observational study.

Setting

Urban, academic hospital in the United States.

Participants

Adult patients (N=3999) admitted to medical units between June 1, 2019, and February 29, 2020, with 2 or more recorded scores on each of 4 tools: Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks Basic Mobility and Daily Activity, Henry Ford Mobility Level, and The Johns Hopkins Highest Level of Mobility.

Interventions

Not applicable.

Main Outcome Measures

Mobility scores and discharge destination.

Results

For the 3999 subjects, 51.4% went home at discharge and had higher mean scores on each measure than those not returning home. Both early (I) and later (II) time point for each measure had positive predictability for discharge home. AM-PAC 6-Clicks had the highest confidence intervals for early and later recorded scores. The c-statistic value for Basic Mobility I (cut point=16) was 0.74 and for II (cut point=18) was, 0.79. The value for Daily Activity I (cut point=18) was 0.75 and for Daily Activity II (cut point=18) was 0.80). The Johns Hopkins Highest Level of Mobility and Henry Ford Mobility Level measures were less discriminative at initial score (c-statistic 0.704 and 0.665, respectively) and final score (c-statistic 0.74 and 0.75, respectively).

Conclusions

Functional outcome measures have good predictive validity for discharge destination. The AM-PAC Basic mobility score appears to have a slightly higher confidence interval than the other tools in this study design.