Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States

Comparison of frailty measures in predicting outcomes after emergency general surgery

INTRODUCTION

Although frailty has been recognized to adversely influence outcomes of emergency general surgery, there are limited data comparing the performance of frailty instruments among this population. We compared the discriminatory power of 4 risk prediction models across a national cohort of patients who underwent emergency general surgery to assess outcomes of interest.

METHODS

Adults undergoing emergency general surgery (large bowel resection, small bowel resection, repair of perforated ulcer, cholecystectomy, appendectomy, lysis of adhesions, or laparotomy) were identified in 2016-2021 Nationwide Readmissions Database. Patients were grouped into frail and non-frail cohorts on the basis of various frailty instruments: Hospital Frailty Risk Score, Modified 5-factor Frailty Index, Modified 11-factor Frailty Index, and Johns Hopkins Adjusted Clinical Groups index. Multivariable regressions were developed to assess independent associations between frailty instruments and in-hospital mortality as well as a composite of perioperative complications.

RESULTS

Of 1,385,505 hospitalizations for emergency general surgery, 57.0%, 29.9%, 26.6%, and 10.5% were identified as frail by mFI-11, Hospital Frailty Risk Score, Modified 5-factor Frailty Index, and Adjusted Clinical Groups, respectively. After multivariable adjustment, Hospital Frailty Risk Score demonstrated the greatest discriminatory power for predicting in-hospital mortality and perioperative complications when compared with other frailty indices. Subjects classified as frail using the Hospital Frailty Risk Score were associated with the greatest risk of mortality (adjusted odds ratio, 7.8; 95% confidence interval, 7.4-8.3) and composite complications (adjusted odds ratio, 8.4; 95% confidence interval, 9.3-8.5) compared with other indices across all frailty levels.

CONCLUSION

Among patients undergoing emergency general surgery, Hospital Frailty Risk Score demonstrated the greatest discrimination in predicting mortality and composite complications. Risk-stratification efforts should prioritize Hospital Frailty Risk Score in elderly patients undergoing emergency general surgery to optimize clinical outcomes and resource allocation.

Non-home discharge in the octogenarian and nonagenarian colorectal cancer population: a retrospective cohort study

PURPOSE

This study aims to determine the rate of non-home discharge (NHD) and identify factors associated with non-home discharge in a colorectal cancer (CRC) population of adults aged 80 years and older. This is the first study looking specifically at NHD as an outcome in the ≥ 80 years colorectal cancer cohort.

METHODS

This is a single-centre retrospective exploratory observational study from a high-volume colorectal cancer unit. Patients aged ≥ 80 years from a prospectively collected CRC database from 2013 to 2020 were included. Electronic medical records were assessed to obtain demographic, clinical, functional and discharge data. Univariable and multivariable logistic regression analyses were performed to identify factors associated with NHD the primary study outcome. Secondary outcomes included discharge disposition and functional decline.

RESULTS

Two hundred forty-two patients aged ≥ 80 years underwent CRC resection. Alo, 234 patients and 221 patients were included in the overall and subgroup non-home discharge analysis. The non-home discharge rate was 19.9% in the cohort that pre-operatively were from home. On multivariable logistic regression, after adjusting for other significant variables, frailty (odds ratio (OR) 2.91, 95% CI 1.25-6.75, p = 0.013), severe complications (OR 3.92, 95% CI 1.40-10.97, p = 0.009) and an open operation (OR 3.93, 95% CI 1.87-8.24, p < 0.001) were associated with a significantly higher rate of NHD. The incidence of functional decline from those at home was 72.4% in the non-home discharge group and 16.7% in those who returned home (p < 0.001).

CONCLUSION

This is the first paper describing the overall rate and identifying factors associated with non-home discharge specifically in the ≥ 80 years CRC population. Prospective studies are required to investigate causality and interventions to reduce non-home discharge rates.

Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis

BACKGROUND

Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort.

METHODS

All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest.

RESULTS

Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (β + 1.04 days, CI + .91-1.17) and greater costs (β+$3,490, CI + 2840-4140).

DISCUSSION

While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Impact of Frailty on Inpatient Mortality and Resource Utilization for Primary Pulmonary Hypertension

Background  Frailty has been associated with inferior outcomes in patients with primary pulmonary hypertension (PPH). There is a lack of national data to assess if hospital frailty risk score (HFRS) is associated with worse inpatient outcomes in PPH. Methods  Our retrospective study used the Nationwide Readmission Database (NRD). First, we extracted all cases older than 18 years who were discharged with a principal diagnosis of PPH between January and November 2016 to 2019 to allow for a 30-day follow-up. Appropriate survey and domain analyses were applied to obtain national estimates using SAS 9.4. Results  We identified 4,555 cases. HFRS <5 was present in 56% ( n  = 2,555) of the cohort. Patients with an intermediate-to-high frailty risk score (HFRS ≥5) were older than those with a low frailty risk score (HFRS <5), with a mean age of 61 versus 54 years ( p  < 0.01), and had slightly fewer women (75 vs. 78%, p  = 0.09). Patients with HFRS >5 had a higher prevalence of dementia, depression, diabetes mellitus, malignancy, acute encephalopathy, coagulopathy, heart failure, and chronic (liver and renal) diseases ( p  < 0.01). Also, they had higher inpatient mortality during index admission (14 vs. 2%, p  < 0.001), and all-cause 30-day readmission rates (38 vs. 33%, p  = 0.01). Univariate analysis suggests a positive correlation between the degree of frailty and the odds of inpatient mortality (referenced to HFRS <5). The HFRS 5 to 10 group has an odds ratio (OR) of 5 (95% confidence interval [CI]: 3.3-8), the HFRS 10 to 15 group has an OR of 14 (95% CI: 8-23), and the HFRS >15 group has an OR of 20 (95% CI: 9-45). Even after adjusting for age, gender, and significant comorbidities, the single most important factor associated with higher odds of inpatient mortality was HFRS >5 (OR: 5.5 [95% CI: 3.7-8.3], p  < 0.001) followed by acute myocardial infarction, acute encephalopathy, heart failure, chronic liver disease, and malnutrition. Length of stay had linear trend with HFRS (mean of 6 days for HFRS <5 vs. 11 days for HFRS 5-10 vs. 19 days for HFRS >10, p  < 0.001). Conclusion  Adverse inpatient outcomes correlate with the severity of HFRS in PPH.

Association of Frailty With Clinical and Financial Outcomes Following Liver Transplantation

INTRODUCTION

Frailty, a measure of physiological aging and reserve, has been validated as a prognostic indicator of mortality in patients with cirrhosis. However, large-scale analyses of the independent association of frailty with clinical and financial outcomes following liver transplantation (LT) are lacking.

METHODS

Adults (≥18 years) undergoing LT were identified in the 2016-2020 National Readmissions Database. Frailty was defined using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable linear and logistic regression models were developed to evaluate the independent association of frailty with in-hospital mortality, perioperative complications, and costs.

RESULTS

Of an estimated 34 442 patients undergoing LT, 8265 (24%) were frail. After adjustment, frailty was associated with greater odds of mortality (adjusted odds ratio [AOR] 1.80; 95% Confidence Interval [CI]: 1.49-1.18), postoperative length of stay (β + 11 days; 95% CI: +10, +12), and hospitalization costs (+$86 880; 95% CI: +75 660, +98 100), as well as a two-fold increase in relative risk of nonhome discharge (AOR 2.17, 95% CI: 1.90-2.49).

CONCLUSIONS

Frailty is associated with an increased risk of in-hospital mortality, complications, and resource utilization among LT recipients. As the proportion of frail LT patients continues to rise, our findings underscore the need for novel risk-stratification and individualized care protocols for such vulnerable patients.

A Novel Frailty Index Can Predict the Short-Term Outcomes of Esophagectomy in Older Patients with Esophageal Cancer

Background: Frailty, rather than age, is associated with postoperative morbidity and mortality. We sought to determine whether preoperative frailty as defined by a novel scoring system could predict the outcomes among older patients undergoing esophagectomy. Methods: We identified patients 65 years or older who underwent esophagectomy between 2011 and 2021 at our institution. Frailty was assessed using the MSK-FI, which consists of 1 component related to functional status and 10 medical comorbidities. We used a multivariable logistic regression model to test for the associations between frailty and short-term outcomes, with continuous frailty score as the predictor and additionally adjusted for age and Eastern Cooperative Oncology Group performance status. Results: In total, 447 patients were included in the analysis (median age of 71 years [interquartile range, 68-75]). Most of the patients underwent neoadjuvant treatment (81%), an Ivor Lewis esophagectomy (86%), and minimally invasive surgery (55%). A total of 22 patients (4.9%) died within 90 days of surgery, 144 (32%) had a major complication, 81 (19%) were readmitted, and 31 (7.2%) were discharged to a facility. Of the patients who died within 90 days, 19 had a major complication, yielding a failure-to-rescue rate of 13%. The risk of 30-day major complications (OR, 1.24 [95% CI, 1.09-1.41]; p = 0.001), readmissions (OR, 1.31 [95% CI, 1.13-1.52]; p < 0.001), and discharge to a facility (OR, 1.86 [95% CI, 1.49-2.37]; p < 0.001) increased with increasing frailty. Frailty and 90-day mortality were not associated. Conclusions: Frailty assessment during surgery decision-making can identify patients with a high risk of morbidity.

Demystifying the association of center-level operative trauma volume and outcomes of emergency general surgery

BACKGROUND

Recent studies have demonstrated a positive volume-outcome relationship in emergency general surgery. Some have advocated for the sub-specialization of emergency general surgery independent from trauma. We hypothesized inferior clinical outcomes of emergency general surgery with increasing center-level operative trauma volume, potentially attributable to overall hospital quality.

METHODS

Adults (≥18 years) undergoing complex emergency general surgery operations (large and small bowel resection, repair of perforated peptic ulcer, lysis of adhesions, laparotomy) were identified in the 2016 to 2020 Nationwide Readmissions Database. Multivariable risk-adjusted models were developed to evaluate the association of treatment at a high-volume trauma center (reference: low-volume trauma center) with clinical and financial outcomes after emergency general surgery. To evaluate hospital quality, mortality among adult hospitalizations for acute myocardial infarction was assessed by hospital trauma volume.

RESULTS

Of an estimated 785,793 patients undergoing a complex emergency general surgery operation, 223,116 (28.4%) were treated at a high-volume trauma center. Treatment at a high-volume trauma center was linked to 1.19 odds of in-hospital mortality (95% confidence interval 1.12-1.27). Although emergency general surgery volume was associated with decreasing predicted risk of mortality, increasing trauma volume was linked to an incremental rise in the odds of mortality after emergency general surgery. Secondary analysis revealed increased mortality for admissions for acute myocardial infarction with greater trauma volume.

CONCLUSION

We note increased mortality for emergency general surgery and acute myocardial infarction in patients receiving treatment at high-volume trauma centers, signifying underlying structural factors to broadly affect quality. Thus, decoupling trauma and emergency general surgery services may not meaningfully improve outcomes for emergency general surgery patients. Our findings have implications for the evolving specialty of emergency general surgery, especially for the safety and continued growth of the acute care surgery model.

Failure to rescue following emergency general surgery: A national analysis

Background

Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event.

Methods

All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR.

Results

Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI.

Conclusion

Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.

Association of socioeconomic vulnerability with outcomes after emergency general surgery

PURPOSE

Social determinants of health are increasingly recognized to shape health outcomes. Yet, the effect of socioeconomic vulnerability on outcomes after emergency general surgery remains under-studied.

METHODS

All adult (≥18 years) hospitalizations for emergency general surgery operations (appendectomy, cholecystectomy, laparotomy, large bowel resection, perforated ulcer repair, or small bowel resection), within 2 days of non-elective admission were tabulated in the 2016 to 2020 Nationwide Readmissions Database. Socioeconomic vulnerability was defined using relevant diagnosis codes and comprised economic, educational, healthcare, environmental, and social needs. Patients demonstrating socioeconomic vulnerability were considered Vulnerable (others: Non-Vulnerable). Multivariable models were constructed to evaluate the independent associations between socioeconomic vulnerability and key outcomes.

RESULTS

Of ∼1,788,942 patients, 177,764 (9.9%) were considered Vulnerable. Compared to Non-Vulnerable, Vulnerable patients were older (67 [55-77] vs 58 years [41-70), P < .001), more often insured by Medicaid (16.4 vs 12.7%, P < .001), and had a higher Elixhauser Comorbidity Index (4 [3-5] vs 2 [1-3], P < .001). After risk adjustment and with Non-Vulnerable as a reference, Vulnerable remained linked with a greater likelihood of in-hospital mortality (adjusted odds ratio 1.64, confidence interval 1.58-1.70) and any perioperative complication (adjusted odds ratio 2.02, confidence interval 1.98-2.06). Vulnerable also experienced a greater duration of stay (β+4.64 days, confidence interval +4.54-4.74) and hospitalization costs (β+$1,360, confidence interval +980-1,740). Further, the Vulnerable cohort demonstrated increased odds of non-home discharge (adjusted odds ratio 2.44, confidence interval 2.38-2.50) and non-elective readmission within 30 days of discharge (adjusted odds ratio 1.29, confidence interval 1.26-1.32).

CONCLUSION

Socioeconomic vulnerability is independently associated with greater morbidity, resource use, and readmission after emergency general surgery. Novel interventions are needed to build hospital screening and care pathways to improve disparities in outcomes.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians: A United States national experience

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥ 90 years are generally considered a higher-risk population for ERCP-related complications.

AIM

To investigate outcomes of ERCP in the Non-agenarian population (≥ 90 years) concerning Frailty.

METHODS

This is a cohort study using the 2018-2020 National Readmission Database. Patients aged ≥ 90 were identified who underwent ERCP, using the international classification of diseases-10 code with clinical modification. Johns Hopkins's adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail. The primary outcome was mortality, and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP. We used univariate and multivariate regression models for analysis.

RESULTS

A total of 9448 patients were admitted for any indications of ERCP. Frail and non-frail patients were 3445 (36.46%) and 6003 (63.53%) respectively. Indications for ERCP were Choledocholithiasis (74.84%), Biliary pancreatitis (9.19%), Pancreatico-biliary cancer (7.6%), Biliary stricture (4.84%), and Cholangitis (1.51%). Mortality rates were higher in frail group [adjusted odds ratio (aOR) = 1.68, P = 0.02]. The Intra-procedural complications were insignificant between the two groups which included bleeding (aOR = 0.72, P = 0.67), accidental punctures/lacerations (aOR = 0.77, P = 0.5), and mechanical ventilation rates (aOR = 1.19, P = 0.6). Post-ERCP complication rate was similar for bleeding (aOR = 0.72, P = 0.41) and post-ERCP pancreatitis (aOR = 1.4, P = 0.44). Frail patients had a longer length of stay (6.7 d vs 5.5 d) and higher mean total charges of hospitalization ($78807 vs $71392) compared to controls (P < 0.001). The 30 d all-cause readmission rates between frail and non-frail patients were similar (P = 0.96).

CONCLUSION

There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail. Larger studies are warranted to investigate and mitigate modifiable risk factors.

Subtypes of Venous Thromboembolism in Inflammatory Bowel Disease: A Nationwide Assessment

Background

Data detailing the risk of Venous Thromboembolism (VTE) subtypes among individuals with Inflammatory bowel disease (IBD) remain limited.Aims: We looked to assess the odds of VTE subtypes among hospitalized individuals with IBD as compared to those without IBD.

Materials & Methods

Using the Nationwide Inpatient Sample database, we applied a multivariable regression analysis to compare the odds of primary VTE-related hospitalizations among individuals with and without IBD from 2016 to 2020, including deep venous thrombosis (DVT), pulmonary embolism (PE), portal vein thrombosis (PVT), Budd Chiari syndrome (BCS), renal vein thrombosis (RVT), and cerebral venous sinus thrombosis (CVST).

Results

Overall, there were 15,565 primary VTE-related hospitalizations among individuals with IBD, as compared to 1,449,164 among individuals without IBD. Having IBD increased the odds for DVT (aOR = 1.34, 95%CI: 1.25-1.43), PVT (aOR = 3.16, 95%CI: 2.65-3.76), and CVST (aOR=1.45, 95%CI: 1.05-2.00), without significant increase in the odds of a PE, BCS, or RVT. Further, individuals with ulcerative colitis (UC) were at a higher risk for the majority of VTE-subtypes as compared to those with Crohn's disease (CD). Among individuals with a VTE-related hospitalization, the presence of IBD was not associated with increased mortality (aOR = 0.77, 95%CI: 0.40-1.50), but was associated with an increased length of stay (CD - 4.8 days, UC - 5.3 days, without IBD - 4.3 days, p<0.01).

Conclusions

Clinicians should retain a high index of suspicion when evaluating VTE-related symptoms among individuals with IBD, as the presence of IBD confers a higher risk of DVT, PVT and CVST related-hospitalizations, and longer stays as compared to individuals without IBD.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation

INTRODUCTION

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking.

METHODS

This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator.

RESULTS

Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge.

CONCLUSIONS

Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Association of dementia with clinical and financial outcomes following lobectomy for lung cancer

Objective

The number of adults with dementia is rising worldwide. Although dementia has been linked with inferior outcomes following various operations, this phenomenon has not been fully elucidated among patients undergoing elective lung resection. Using a national cohort, we evaluated the association of dementia with clinical and financial outcomes following lobectomy for cancer.

Methods

Adults undergoing lobectomy for lung cancer were identified within the 2010-2020 Nationwide Readmissions Database. Patients with a comorbid diagnosis of dementia were considered the Dementia cohort (others: Non-Dementia). Multivariable regressions were developed to evaluate the association between dementia and key outcomes.

Results

Of ∼314,436 patients, 2863 (0.9%) comprised the Dementia cohort. Compared with Non-Dementia, the Dementia cohort was older (75 vs 68 years, P < .001), less commonly female (49.4 vs 53.9%, P = .01), and had a greater burden of comorbid conditions. After adjustment, dementia remained associated with similar odds of in-hospital mortality (adjusted odds ratio [aOR], 0.86; 95% confidence interval [CI], 0.54-1.38) but greater likelihood of pneumonia (aOR, 1.31; CI, 1.04-1.65) and infectious complications (aOR, 1.37; CI, 1.01-1.87). Further, dementia was associated with longer length of stay (β +0.96 days; CI, 0.51-1.41), but no difference in hospitalization cost (β $1528; CI, -92 to 3148).

Conclusions

Patients with dementia faced similar odds of mortality, but greater complications and resource use following lobectomy for lung cancer. Novel interventions are needed to improve care coordination and develop standardized recovery pathways for this growing cohort.

Failure to rescue among octogenarians undergoing cardiac surgery in the United States

BACKGROUND

A rapidly growing population, octogenarians are considered at high-risk for mortality and complications after cardiac surgery. Given the recent addition of failure to rescue as a Society of Thoracic Surgeons quality metric, a better understanding of patient and operative factors predictive of failure to rescue in this cohort is warranted.

METHODS

The 2010-2020 Nationwide Readmissions Database was used to identify all patients ≥80 years undergoing first-time, elective coronary artery bypass grafting or concomitant valve operations. Patients experiencing failure to rescue, defined as mortality after a major or minor complication, were classified as Failure to Rescue (others: Non-Failure to Rescue). Multivariable regression models were developed to ascertain significant perioperative factors associated with failure to rescue.

RESULTS

Of ∼562,794 octogenarian patients, 76,473 (13.6%) developed complications. Of these, 7,055 (9.2%) experienced failure to rescue. The incidence of failure to rescue decreased across the study time course (9.7% in 2010 to 7.6% in 2019, P = .001). After risk adjustment, age (adjusted odds ratio, 1.05/year; 95% confidence interval, 1.03-1.07), female sex (adjusted odds ratio, 1.40; 95% confidence interval, 1.27-1.53), congestive heart failure (adjusted odds ratio, 1.54; 95% confidence interval, 1.38-1.71), late-stage kidney disease (adjusted odds ratio, 2.38; 95% confidence interval, 1.79-3.17), liver disease (adjusted odds ratio, 9.59; 95% confidence interval, 8.17-11.26), and cerebrovascular disease (adjusted odds ratio, 2.42; 95% confidence interval, 2.12-2.76) were associated with failure to rescue. Relative to isolated coronary artery bypass grafting, combined coronary artery bypass grafting-valve (adjusted odds ratio, 1.67; 95% confidence interval, 1.43-1.95) and multi-valve procedures (adjusted odds ratio, 2.23; 95% confidence interval, 1.75-2.85) were linked with greater odds of failure to rescue. There was no association between failure to rescue and hospital volume.

CONCLUSION

Despite improvements in perioperative management, failure to rescue occurs in ∼9% of octogenarians undergoing elective cardiac operations. Although incidence has declined over the past decade, the continued prevalence of failure to rescue underscores the need for novel risk assessments and targeted interventions.

Colonoscopy in the nonagenarian population

BACKGROUND

With increasing life expectancy, there is an increasing proportion of nonagenarians undergoing both elective and emergency surgical procedures. The decision as to whom will benefit from surgical procedures is however difficult to ascertain and still remains a challenge to clinicians. This study is aimed to evaluate the clinical outcomes of colonoscopy in the nonagenarian population, and to determine if the outcomes are acceptable for us to continue to offer such interventions.

METHODS

Retrospective study of patients of Dr. G.R (Gastroenterologist) and Dr. W.B (Colorectal Surgeon) between 1 January 2018 and 31 November 2022. All patients who were ≥90 years old and had a colonoscopy was included in the study. Exclusion criteria were patients who were less than 90 years old, had a flexible sigmoidoscopy or colonoscopy as part of their surgical procedure.

PRIMARY OUTCOME MEASURES

post-colonoscopy complications and length of stay.

SECONDARY OUTCOME MEASURES

reasons for colonoscopy, significant colonoscopy findings, 30-day morbidity and mortality.

RESULTS

Sixty patients were included in the study. Median age was 91 (90-100) years old. 33.3% of the patients were males. Seventy percent of the patients were ASA 3. Median length of hospital stay was 1 day. 11.7% of patients were found to have colorectal malignancy. There were no complications after the colonoscopy. There were no 30-day re-admission, morbidity or mortality.

CONCLUSION

Colonoscopy can be performed safely in carefully selected nonagenarian patients with acceptable low complication rates.

Impact of frailty on clinical outcomes and resource utilization of hospitalizations for renal stone surgery

PURPOSE

Frailty is reportedly associated with poorer outcomes among surgical patients. Using a coding-based frailty tool, we investigated the impact of frailty on clinical outcomes and resource utilization for urolithiasis hospitalizations.

METHODS

A cohort study using the 2018 National Inpatient Sample database. All adult elective hospitalizations for urolithiasis were included in the study. The study population was categorized into FRAIL and non-frail (nFRAIL) cohorts using the Johns Hopkins Adjusted Clinical Groups frailty clusters. The association between frailty and clinical and financial outcomes was evaluated using multivariate regression models.

RESULTS

About 1028 (14.9%) out of 6900 total hospitalizations were frail. Frailty was not associated with a significant increase in the odds of in-hospital mortality (adjusted odds ratio (aOR) 1.73, 95% CI 0.15-20.02) or length of hospital stay, but was associated with a lower chance of surgery within 24 h of admission (aOR 0.65, 95% CI 0.48-0.90, P = 0.008). A higher Charlson index was independently associated with an over 100% increase in the odds of in-hospital mortality (aOR 2.091, 95% CI 1.53-2.86, P < 0.001). Frail patients paid $15,993 higher in total hospital costs and had a higher likelihood of non-home discharges (aOR 4.29, 95% CI 2.74-6.71, P < 0.001) and peri-operative complications (aOR 1.77, 95% CI 1.14-2.73, P = 0.01).

CONCLUSION

Frailty was correlated with unfavorable outcomes, except mortality and prolonged hospital stay. Incorporating frailty evaluation into risk models has the potential to enhance patient selection and preparation for urolithiasis intervention.

Measuring the Predictive Accuracy of Preoperative Clinical Frailty Instruments Applied to Electronic Health Data in Older Patients Having Emergency General Surgery: A Retrospective Cohort Study

OBJECTIVE

To compare predictive accuracy of frailty instruments operationalizable in electronic data for prognosticating outcomes among older adults undergoing emergency general surgery (EGS).

BACKGROUND

Older patients undergoing EGS are at higher risk of perioperative morbidity and mortality. Preoperative frailty is a common and strong perioperative risk factor in this population. Despite this, existing barriers preclude routine preoperative frailty assessment.

METHODS

We conducted a retrospective cohort study of adults above 65 undergoing EGS from 2012 to 2018 using Institute for Clinical Evaluative Sciences (ICES) provincial healthcare data in Ontario, Canada. We compared 4 frailty instruments: Frailty Index (FI), Hospital Frailty Risk Score (HFRS), Risk Analysis Index-Administrative (RAI), ACG Frailty-defining diagnoses indicator (ACG). We compared predictive accuracy beyond baseline risk models (age, sex, American Society of Anesthesiologists' score, procedural risk). Predictive performance was measured using discrimination, calibration, explained variance, net reclassification index and Brier score (binary outcomes); using explained variance, root mean squared error and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes were 365-day mortality, nonhome discharge, days alive at home, length of stay, and 30-day and 365-day health systems cost.

RESULTS

A total of 121,095 EGS patients met inclusion criteria. Of these, 11,422 (9.4%) experienced death 30 days postoperatively. Addition of FI, HFRS, and RAI to the baseline model led to improved discrimination, net reclassification index, and R2 ; RAI demonstrated the largest improvements.

CONCLUSIONS

Adding 4 frailty instruments to typically assessed preoperative risk factors demonstrated strong predictive performance in accurately prognosticating perioperative outcomes. These findings can be considered in developing automated risk stratification systems among older EGS patients.

Trends and outcomes of emergency general surgery in elderly and highly elderly population in a single regional emergency center

Purpose

The number of elderly patients, especially aged ≥80 years, undergoing emergency surgery is gradually increasing. The aim of this study was to find out the trends and results of emergency general surgery for elderly patients over 9 years in an emergency medical center in South Korea, where the population is aging most rapidly.

Methods

The clinical characteristics, outcomes, and medical expenses of emergency general surgery for the elderly (aged 65-79 years) and highly elderly (aged ≥80 years) patients who visited to a regional emergency medical center from 2012 to 2020 were analyzed.

Results

The number of highly elderly patients increased with each 3-year interval, whereas the proportion of patients aged 19-79 years was similar, and that of pediatric patients was decreasing. The higher the age group, the higher the mortality (young adult vs. elderly vs. highly elderly: odds ratio [OR], 1 vs. 3.689 vs. 11.293; P < 0.001) and complication rates (OR, 1 vs. 2.840 vs. 4.633; P < 0.001), and longer length of hospital stay (β = 0.949, P = 0.001) even after adjusting for the type of surgery and the American Society of Anesthesiologists physical status classification. Non-covered medical expenses were significantly related to the age groups (β = 151,608.802, P < 0.001).

Conclusion

The higher age group was associated with increased number of unfavorable outcomes after emergency general surgery, along with increased medical cost. Efforts to prevent emergency surgery for elderly patients and a specialized treatment system are needed.

Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians

BACKGROUND

Coronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population.

METHODS

Patients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010-2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes.

RESULTS

Of ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73-1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78-1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71-1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60-1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74-1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75-1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16-1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83-0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval -$2,370 to $200).

CONCLUSION

Off-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.

Thyroid surgery outcomes in octogenarians: A national analysis

BACKGROUND

The incidence of thyroid pathology increases with age. Yet octogenarians may face increased rates of complications after thyroid surgery. Using a nationally representative cohort, we evaluated the outcomes of thyroidectomy among octogenarians.

METHODS

All patients ≥55 years who underwent inpatient thyroidectomy were identified using the 2010 to 2020 National Readmissions Database. Patients ≥80 years were classified as octogenarians (others: nonoctogenarians). Multivariable models were built to evaluate independent associations between octogenarians and key clinical and financial outcomes.

RESULTS

Of 120,164 hospitalizations, 9,163 (7.6%) were octogenarians. The proportion of octogenarians undergoing thyroidectomy increased from 7.7% (2010) to 8.7% (2020) (nptrend <0.001). Octogenarians were more frequently female (72.1 vs 70.5%, P < .001), presented with a higher Elixhauser comorbidity index (3 [2-4] vs 2 [1-3], P < .001), and more commonly faced thyroid cancer (41.3 vs 32.7%, P < .001). After risk adjustment, octogenarians were associated with greater odds of experiencing any perioperative complication (adjusted odds ratio 1.36, 95% confidence interval 1.25-1.48). Octogenarians were further linked with greater odds of respiratory (adjusted odds ratio 1.82, 95% confidence interval 1.52-2.17) and renal complications (adjusted odds ratio 1.90, 95% confidence interval 1.45-2.49), dysphagia (adjusted odds ratio 1.51, 95% confidence interval 1.33-1.72), laryngeal edema (adjusted odds ratio 2.03, 95% confidence interval 1.30-3.18), vocal cord paralysis (adjusted odds ratio 1.79, 95% confidence interval 1.53-2.09), and stridor (adjusted odds ratio 1.42, 95% confidence interval 1.01-2.00). No difference in hypocalcemia was observed. Furthermore, octogenarians demonstrated an increased likelihood of in-hospital mortality (adjusted odds ratio 6.34, 95% confidence interval 3.11-12.53), hospitalization expenditures (+$910, 95% confidence interval +$420-1,400), and nonelective readmission within 30 days of discharge (adjusted odds ratio 1.54, 95% confidence interval 1.32-1.79).

CONCLUSION

Octogenarians are associated with greater morbidity after thyroidectomy. Patients ≥80 years should be counseled about increased perioperative risk when discussing surgical versus nonsurgical treatments for thyroid disease.

Markers of sarcopenia increase 30-day mortality following emergency laparotomy: A systematic review

BACKGROUND AND OBJECTIVE

Decreased skeletal muscle mass and quality are one of the several markers used for sarcopenia diagnosis and are generally associated with increased rates of post-operative infections, poorer recovery and increased mortality. The aim of this review was to evaluate methods applied to detect markers of sarcopenia and the associated outcomes for patients undergoing emergency laparotomy.

METHODS

This review was conducted with reference to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase and Google Scholar databases were searched. Studies detecting patients with sarcopenia or skeletal muscle decline markers and the associated outcomes after emergency laparotomy surgery were considered. The Newcastle-Ottawa Scale was used to evaluate publication quality.

RESULTS

Out of 103 studies, which were screened, 19 full-text records were reviewed and 7 studies were ultimately analyzed. The study cohort sizes ranged from n = 46 to n = 967. The age range was 36-95 years. There were 1107 females (53%) and 973 males (47%) across all 7 studies. All studies measured psoas muscle mass and three studies assessed psoas muscle quality using computerized tomography (CT) imaging. No study assessed muscle strength or function, while five studies showed an association between low muscle mass and increased mortality rates after emergency laparotomy. Among the three studies, which assessed muscle quality, two of three studies showed poorer 30-day survival rates.

CONCLUSIONS

The existing literature is limited, however it indicates that low psoas muscle mass and quality markers are associated with increased 30-day mortality rates after emergency laparotomy. Therefore, muscle markers can be used as a new feasible tool to identify most at risk patients requiring further interventions.

Differences Among Clinical Trials and Registries on Surgical and Percutaneous Coronary Interventions

BACKGROUND

A need exists for systematic evaluation of the differences in baseline characteristics and early outcomes between patients enrolled in randomized controlled trials (RCTs) and clinical practice for coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

METHODS

Systematic searches were conducted to identify RCTs comparing CABG vs PCI and CABG or PCI registries. Sixteen predefined baseline characteristics and 30-day mortality were extracted from the included studies. Pooled proportion and mean with 95% CI were calculated for binary and continuous outcomes, respectively, by using the random effects model.

RESULTS

Fourteen RCTs and 10 registries including more than 2 million patients were included. Registry patients who underwent CABG had a higher prevalence of hypertension, smoking, reduced left ventricular ejection fraction, and prior myocardial infarction, but a lower prevalence of single-vessel disease when compared with CABG-treated patients included in RCTs. Regarding PCI, hypertension, hyperlipidemia, left main coronary artery disease, triple-vessel coronary disease, and NYHA functional class <IV were significantly more prevalent among patients in RCTs, whereas age, reduced left ventricular ejection fraction, and smoking were more represented among PCI registry patients. Thirty-day mortality was higher in registries for both PCI-treated and CABG-treated patients.

CONCLUSIONS

There were significant differences in baseline characteristics and 30-day mortality between patients enrolled in RCTs comparing CABG vs PCI and CABG and PCI registries. However, results were mixed, and the discrepancy was less than seen in other fields.

Association of frailty with outcomes of resection for colonic volvulus: A national analysis

Background

With limited national studies available, we characterized the association of frailty with outcomes of surgical resection for colonic volvulus.

Methods

Adults with sigmoid or cecal volvulus undergoing non-elective colectomy were identified in the 2010–2019 Nationwide Readmissions Database. Frailty was identified using the Johns Hopkins indicator which utilizes administrative codes. Multivariable models were developed to examine the association of frailty with in-hospital mortality, perioperative complications, stoma use, length of stay, hospitalization costs, non-home discharge, and 30-day non-elective readmissions.

Results

An estimated 66,767 patients underwent resection for colonic volvulus (Sigmoid: 39.6%; Cecal: 60.4%). Using the Johns Hopkins indicator, 30.3% of patients with sigmoid volvulus and 15.9% of those with cecal volvulus were considered frail. After adjustment, frail patients had higher risk of mortality compared to non-frail in both sigmoid (10.6% [95% CI 9.47–11.7] vs 5.7% [95% CI 5.2–6.2]) and cecal (10.4% [95% CI 9.2–11.6] vs 3.5% [95% CI 3.2–3.8]) volvulus cohorts. Frailty was associated with greater odds of acute venous thromboembolism occurrences (Sigmoid: AOR 1.50 [95% CI 1.18–1.94]; Cecal: AOR 2.0 [95% CI 1.50–2.72]), colostomy formation (Sigmoid: AOR 1.73 [95% CI 1.57–1.91]; Cecal: AOR 1.48 [95% CI 1.10–2.00]), non-home discharge (Sigmoid: AOR 1.97 [95% CI 1.77–2.20]; Cecal: AOR 2.56 [95% CI 2.27–2.89]), and 30-day readmission (Sigmoid: AOR 1.15 [95% CI 1.01–1.30]; Cecal: AOR 1.26 [95% CI 1.10–1.45]). Frailty was associated with incremental increase in length of stay (Sigmoid: +3.4 days [95% CI 2.8–3.9]; Cecal: +3.8 days [95% CI 3.3–4.4]) and costs (Sigmoid: +$7.5k [95% CI 5.9–9.1]; Cecal: +$12.1k [95% CI 10.1–14.1]).

Conclusion

Frailty, measured using a simplified administrative tool, is associated with significantly worse clinical and financial outcomes following non-elective resections for colonic volvulus. Standard assessment of frailty may aid risk-stratification, better inform shared-decision making, and guide healthcare teams in targeted resource allocation in this vulnerable patient population.

Impact of Venous Thromboembolism on Readmissions and Resource Use Following Emergency General Surgery

BACKGROUND

Acute deep vein thrombosis and pulmonary embolism collectively known as venous thromboembolism (VTE), are associated with increased risk of poor clinical sequelae during inpatient hospitalizations. We examined the association of VTE with mortality, readmissions, and costs among patients undergoing emergency general surgery (EGS) operations using a national cohort.

METHODS

Adult hospitalizations for EGS (laparotomy, small bowel resection, large bowel resection, appendectomy, lysis of adhesions, cholecystectomy, and repair of perforated ulcer) within two days of admission were identified in the 2016-18 Nationwide Readmissions Database. Hospitalizations were stratified based on diagnosis of VTE and others (n-VTE).

RESULTS

Of an estimated 860, 747 ;27,700;23,100;28,300 EGS patients, .87% developed VTE during the index hospitalization. Patients in the VTE group were on average older (65.5 ± 15.3 vs 54.8 ± 18.6 years, P < .001) and more commonly male (46.7 vs 39.3%, P < .001). Venous thromboembolism was independently associated with greater odds of mortality (AOR:1.7 95% CI 1.6-1.9), increased costs ( +27 700 95% CI 23 100-28 300) and greater odds of 30-day readmissions (AOR 1.3 95% CI 1.2-1.4).

DISCUSSION

Despite national efforts to reduce its incidence, VTE affects nearly 1/100 EGS patients and is associated with increased odds of mortality as well as costs, and readmissions. Tailored approaches are warranted to reduce the impact of this pernicious complication.

Association of Frailty with Perioperative Outcomes Following Hepatic Resection: A National Study

OBJECTIVES

Risk of mortality and major comorbidity remains high following hepatic resection. Given recent advancements in nonsurgical techniques to control hepatic malignancy, accurate assessment of surgical candidates, especially those considered frail, has become imperative. The present study aimed to characterize the impact of frailty on clinical and financial outcomes following hepatic resection in older individuals.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All older adults (≥65 years) undergoing elective hepatic resection were identified from the 2012 to 2019 National Inpatient Sample.

METHODS

Frailty was defined by using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Multivariable regression models were developed to assess the independent association of frailty with mortality, perioperative complications, and resource utilization. Marginal effects were tabulated to assess the impact of hospital volume on frailty-associated mortality.

RESULTS

Of an estimated 40,735 patients undergoing major hepatic resection, 9.0% were considered frail. After multivariable adjustment, frailty was associated with increased odds of mortality (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 2.0-4.3; P < .001) and perioperative complication (AOR 2.9; 95% CI 2.4-3.4; P < .001). Furthermore, frail patients incurred longer risk-adjusted length of stay (14.2 vs 6.7 days, P < .001) and greater hospitalization costs ($55,100 vs $29,300, P < .001). In assessing the impact of institutional expertise on perioperative outcomes, the marginal effect of frailty on mortality became less pronounced with increasing operative volume.

CONCLUSIONS AND IMPLICATIONS

As the population of the United States continues to age, surgeons are increasingly likely to encounter candidates for major hepatic resection who are frail. The present study associated frailty with inferior clinical and financial outcomes; however, frailty-associated mortality became less pronounced at centers with high hepatic resection operative volume. Coding-based instruments, such as the Johns Hopkins Adjusted Clinical Groups, may identify patients from electronic medical records who may benefit from further geriatric assessment and targeted treatments.