Alive and at home: Five-year outcomes in older adults following emergency general surgery

Early primary care follow-up is associated with improved long-term functional outcomes among injured older adults

BACKGROUND

Older adults who survive injury frequently experience functional decline, and interventions preventing this decline are needed. We therefore evaluated the association between early primary care physician (PCP) follow-up and nursing home admission or death among injured older adults.

METHODS

We performed a retrospective, population-based cohort study of community-dwelling older adults (65 years or older) discharged alive after injury-related hospitalization (2009-2020). The exposure of interest was early PCP visit (within 14 days of discharge). The primary outcome was time to death or nursing home admission in the year after discharge. Cox proportional hazards models were used to evaluate the relationship between early PCP visit and this outcome, adjusting for baseline characteristics.

RESULTS

Among 93,482 patients (63.7% female; mean age, 79.8 years), 24,167 (25.9%) had early follow-up with their own PCP and 6,083 (6.5%) with a different PCP. In the year after discharge, 16,676 patients (17.8%) died or were admitted to a nursing home. After risk adjustment, early follow-up with one's own PCP was associated with a 15% reduction in the hazard of death or nursing home admission relative to no follow-up (hazard ratio, 0.85; 95% confidence interval, 0.83-0.87). Follow-up with a different PCP was not associated with the outcome (hazard ratio, 0.99; 95% confidence interval, 0.95-1.03). These relationships were consistent across all age, sex, frailty, and injury severity strata.

CONCLUSION

Among injured older adults, early follow-up with their own PCP was associated with increased time alive and at home. These findings suggest strategies to integrate PCPs into postinjury care of older adults should be explored.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Days at home after surgery as a perioperative outcome: scoping review and recommendations for use in health services research

BACKGROUND

Days at home after surgery is a promising new patient-centred outcome metric that measures time spent outside of healthcare institutions and mortality. The aim of this scoping review was to synthesize the use of days at home in perioperative research and evaluate how it has been termed, defined, and validated, with a view to inform future use.

METHODS

The search was run on MEDLINE, Embase, and Scopus on 30 March 2023 to capture all perioperative research where days at home or equivalent was measured. Days at home was defined as any outcome where time spent outside of hospitals and/or healthcare institutions was calculated.

RESULTS

A total of 78 articles were included. Days at home has been increasingly used, with most studies published in 2022 (35, 45%). Days at home has been applied in multiple study design types, with varying terminology applied. There is variability in how days at home has been defined, with variation in measures of healthcare utilization incorporated across studies. Poor reporting was noted, with 14 studies (18%) not defining how days at home was operationalized and 18 studies (23%) not reporting how death was handled. Construct and criterion validity were demonstrated across seven validation studies in different surgical populations.

CONCLUSION

Days at home after surgery is a robust, flexible, and validated outcome measure that is being increasingly used as a patient-centred metric after surgery. With growing use, there is also growing variability in terms used, definitions applied, and reporting standards. This review summarizes these findings to work towards coordinating and standardizing the use of days at home after surgery as a patient-centred policy and research tool.

Primary care follow-up improves outcomes in older adults following emergency general surgery admission

BACKGROUND

While preoperative optimization improves outcomes for older adults undergoing major elective surgery, no such optimization is possible in the emergent setting. Surgeons must identify postoperative interventions to improve outcomes among older emergency general surgery (EGS) patients. The objective of this cohort study was to examine the association between early follow-up with a primary care physician (PCP) and the risk of nursing home acceptance or death in the year following EGS admission among older adults.

METHODS

Using population-based administrative health data in Ontario, Canada (2006-2016), we followed all older adults (65 years or older) for 1 year after hospital admission for EGS conditions. A multivariable Cox model was used to identify the association between early postdischarge follow-up with a patient's PCP and the time to nursing home acceptance or death while adjusting for confounders.

RESULTS

Among 76,568 older EGS patients, 32,087 (41.9%) were seen by their usual PCP within 14 days of discharge, and 9,571 (12.5%) were accepted to a nursing home or died within 1 year. Primary care physician follow-up was associated with a 13% reduced risk of nursing home acceptance or death compared with no follow-up (hazard ratio 0.87; 95% confidence interval 0.84-0.91). This effect was consistent across age and frailty strata, patients managed operatively and nonoperatively, and patients who had both high and low baseline continuity of care with their PCP.

CONCLUSION

Early follow-up with a familiar PCP was associated with a reduced risk of nursing home acceptance or death among older adults following EGS admission. Structures and processes of care are needed to ensure that such follow-up is routinely arranged at discharge.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients

IMPORTANCE

Many conventional end points in randomized clinical trials of interventions for critically ill patients do not account for patient-centered concerns such as time at home, physical function, and quality of life after critical illness.

OBJECTIVE

To establish whether days alive and at home at day 90 (DAAH90) is associated with long-term survival and functional outcomes in mechanically ventilated patients.

DESIGN, SETTING, AND PARTICIPANTS

The RECOVER prospective cohort study was conducted from February 2007 to March 2014, using data from 10 intensive care units (ICUs) in Canada. Patients were included in the baseline cohort if they were aged 16 years or older and underwent invasive mechanical ventilation for 7 or more days. The follow-up cohort analyzed here comprised RECOVER patients who were alive and had functional outcomes ascertained at 3, 6, and 12 months. Secondary data analysis occurred from July 2021 to August 2022.

EXPOSURES

Composite of survival and days alive and at home at day 90 after ICU admission (DAAH90).

MAIN OUTCOMES AND MEASURES

Functional outcomes at 3, 6, and 12 months were evaluated with the Functional Independence Measure (FIM), the 6-Minute Walk Test (6MWT), the Medical Research Council (MRC) Scale for Muscle Strength, and the 36-Item Short Form Health Survey physical component summary (SF-36 PCS). Mortality was evaluated at 1 year from ICU admission. Ordinal logistic regression was used to describe the association between DAAH90 tertiles and outcomes. Cox proportional hazards regression models were used to examine the independent association of DAAH90 tertiles with mortality.

RESULTS

The baseline cohort comprised 463 patients. Their median age was 58 years (IQR, 47-68 years), and 278 patients (60.0%) were men. In these patients, Charlson Comorbidity Index score, Acute Physiology and Chronic Health Evaluation II score, ICU intervention (eg, kidney replacement therapy or tracheostomy), and ICU length of stay were independently associated with lower DAAH90. The follow-up cohort comprised 292 patients. Their median age was 57 years (IQR, 46-65 years), and 169 patients (57.9%) were men. Among patients who survived to day 90, lower DAAH90 was associated with higher mortality at 1 year after ICU admission (tertile 1 vs tertile 3: adjusted hazard ratio [HR], 0.18 [95% CI, 0.07-0.43]; P < .001). At 3 months of follow-up, lower DAAH90 was independently associated with lower median scores on the FIM (tertile 1 vs tertile 3, 76 [IQR, 46.2-101] vs 121 [IQR, 112-124.2]; P = .04), 6MWT (tertile 1 vs tertile 3, 98 [IQR, 0-239] vs 402 [IQR, 300-494]; P < .001), MRC (tertile 1 vs tertile 3, 48 [IQR, 32-54] vs 58 [IQR, 51-60]; P < .001), and SF-36 PCS (tertile 1 vs tertile 3, 30 [IQR, 22-38] vs 37 [IQR, 31-47]; P = .001) measures. Among patients who survived to 12 months, being in tertile 3 vs tertile 1 for DAAH90 was associated with higher FIM score at 12 months (estimate, 22.4 [95% CI, 14.8-30.0]; P < .001), but this association was not present for ventilator-free days (estimate, 6.0 [95% CI, -2.2 to 14.1]; P = .15) or ICU-free days (estimate, 5.9 [95% CI, -2.1 to 13.8]; P = .15) at day 28.

CONCLUSIONS AND RELEVANCE

In this study, lower DAAH90 was associated with greater long-term mortality risk and worse functional outcomes among patients who survived to day 90. These findings suggest that the DAAH90 end point reflects long-term functional status better than standard clinical end points in ICU studies and may serve as a patient-centered end point in future clinical trials.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

OBJECTIVE

To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.

ELIGIBILITY CRITERIA

Studies reporting data on the incidence and outcomes of AMI in adult populations.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.

RESULTS

From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).

CONCLUSIONS

In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.

PROSPERO REGISTRATION NUMBER

CRD42021247148.

Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis

Background

International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis.

Method

1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery.

Results

725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months.

Conclusion

Patients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery.

Trial registration: Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02453-0.

Complicated Abdominal Wall Hernias in the Elderly: Time Is Life and Comorbidities Matter

BACKGROUND

Abdominal wall hernias represent a common problem that can present as surgical emergencies with increased morbidity and mortality. The data examining outcomes in elderly patients with hernia emergencies is scant.

METHODS

The 2007-2017 ACS-NSQIP database was queried. Patients ≥65 years old with a diagnosis of acute complicated abdominal wall hernia were included. Univariable and multivariable analyses were used to identify independent predictors of 30-day mortality and surgical site infection (SSI).

RESULTS

Main predictors of 30-day mortality were admission from nursing home or chronic care facility (OR = 1.62, 95% CI: 1.10-2.38, P = .014), transfer from outside ED (OR = 1.81, 95% CI: 1.31-2.51, P < .001), days from admission to operation (OR = 1.05, 95% CI: 1.02-1.08, P = .002), recent significant weight loss (OR = 1.95, 95% CI: 1.12-3.37, P = .018), pre-operative septic shock (OR = 4.13, 95% CI: 2.44-6.99, P < .001), ventilator dependence (OR = 2.50, 95% CI: 1.29-4.81, P = .006), and ASA status. When compared to open repair, laparoscopic repair emerged as protective against SSI (OR = .34, 95% CI: .17-.66, P = .001). Bowel resection (OR = 2.15, 95% CI: 1.63-2.84, P < .001) and increasing wound class were risk factors for SSI.

CONCLUSION

In the elderly patient presenting with an acute complicated abdominal wall hernia, time to surgery is crucial for survival, and comorbidities influence outcome. Laparoscopy is an option in management due to its decreased risk of surgical site infection without increased mortality, whenever patient factors are favorable for this approach.

Not all is lost: Functional recovery in older adults following emergency general surgery

BACKGROUND

Although functional decline and death are common long-term outcomes among older adults following emergency general surgery (EGS), we hypothesized that patients' post-discharge function may wax and wane over time. Periods of fluctuation in function may represent opportunities to intervene to prevent further decline. Our objective was to describe the functional trajectories of older adults following EGS admission.

METHODS

This was a population-based retrospective cohort study of all independent, community-dwelling older adults (age ≥ 65) in Ontario with an EGS admission (2006-2016). A multistate model was used to examine patients' functional trajectories over the five years following discharge. Patients were followed as they transitioned back and forth between functional independence, use of chronic home care (in-home assistance for personal care, homemaking, or medical care for at least 90 days), nursing home admission, and death.

RESULTS

We identified 78,820 older adults with an EGS admission (mean age 77, 53% female). In the 5 years following admission, 32% (n = 24,928) required new chronic home care, 21% (n = 5,249) of whom had two or more episodes of chronic home care separated by periods of independence. The average time spent in chronic home care was 11 months, and 50% (n = 12,679) of chronic home care episodes ended with a return to independence. For patients requiring chronic home care at any time, the probability of returning to independent living over the subsequent five years ranged from 36-43% annually.

CONCLUSIONS

Not all is lost for older adults who experience functional decline following EGS admission. Half of those who require chronic home care will recover to independence, and one-third will have a durable recovery, remaining independent after five years. Fluctuations in function in the years following EGS may represent a unique opportunity for interventions to promote rehabilitation and recovery among older adults.

LEVEL OF EVIDENCE

Level III, epidemiological.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

A Population-Based Analysis of Long-Term Outcomes Among Older Adults Requiring Unexpected Intensive Care Unit Admission After Cancer Surgery

BACKGROUND

High-intensity cancer surgery is increasingly common among older adults. However, these patients are at high-risk for unexpected intensive care unit (ICU) admissions after surgery. How these admissions impact older adults' long-term outcomes is unknown.

METHODS

We performed a population-based, cohort study of older adults (age ≥ 70 years) who underwent high-intensity cancer surgery from 2007 to 2017. Analyses were performed to examine time alive and at home following surgery, defined as time from surgery to nursing home admission or death. Patients were followed for up to 5 years. Extended Cox proportional hazards models examined the independent association between unexpected ICU admission (ICU admissions excluding routine postoperative monitoring) and remaining alive and at home. Subgroup analysis stratified patients by duration of mechanical ventilation (MV).

RESULTS

Of 47,367 identified older adults, 7372 (15.6%) had an unexpected ICU admission. Patients with an unexpected ICU admission had a significantly lower probability of being alive and at home at 5 years (26.2%; 95% confidence interval [CI] 25.1-27.2%) compared with those without an unexpected admission (56.8%; 95% CI 56.3-57.4%). After adjusting for baseline characteristics, unexpected ICU admission remained associated with less time alive and at home. The elevated risk of death or nursing home admission persisted for 5 years after surgery (years 2-5: hazard ratio [HR] 1.58, 95% CI 1.50-1.66). Duration of MV was inversely associated with time alive and at home.

CONCLUSIONS

Older adults with an unexpected ICU admission after high-intensity cancer surgery are at increased risk for death or admission to a nursing home for at least 5 years.