CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.
Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients vs. 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.
He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.
Of the 167 patients, 29 (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, said Dr. Wiktor.
Operative time and blood loss did not differ significantly between the two groups. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group; mean blood loss was 561 mL vs. 603 mL, respectively.
Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years vs. 64 years), had a longer ICU stay (11 days vs. 6 days), and had a longer overall hospital stay (20 days vs. 9 days) than those discharged to home.
“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said.
Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. Admitted patients had a mean score of 2.6 vs. 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients vs. 97.4 in those discharged to home, as measured on the Barthel Index scale.
My Take
Stratify Patients' Risks
Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.
It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.
The more precise we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.
FRANK MICHOTA, M.D., is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.
DR. MICHOTA