Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures
Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures
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DOI：
10.1001/jamasurg.2016.1689
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发表时间：
2016-09-01
期刊：
影响因子：
16.9
通讯作者：
Robinson, Thomas N.
中科院分区：
文献类型：
--
作者：
Berian, Julia R.;Mohanty, Sanjay;Robinson, Thomas N.
老年人在手术后发生不良事件的风险增加。目的评估外科手术后老年患者的独立丧失情况，并考察其与老年患者再入院和出院的关系。设计、设置和参与者这项回顾性队列研究从2014年1月至2014年12月在26家医院参加了美国外科医师学会国家外科质量改进计划老年外科试点项目，对9972名年龄在65岁及以上的老年患者进行了调查。共有4895名患者被排除在外，因为他们完全依赖，美国麻醉学家协会将他们归类为5类，接受矫形或脊柱手术，或在出院前死亡。EXPOSURES出院时失去独立性。主要结果和衡量出院后再入院和死亡的指标。结果在本研究纳入的5077名患者中，2736名(53.9%)为女性，3876名(76.3%)为白人，平均年龄75(7)岁。在这个队列中，LOI随着年龄的增长而增加；年龄在65-74岁的2780名患者中，有1386名(49.9%)发生了LOI，75-84岁的1726名患者中有1162名(67.3%)发生了LOI，在571名85岁及以上的患者中有479名(83.9%)发生了LOI(P<；.001)。再入院517例(10.2%)。在风险调整模型中，LOI与再入院(优势比，1.7；95%可信区间，1.4-2.2)和术后并发症(优势比，6.7；95%可信区间，4.9-9.0)密切相关。出院后死亡69例(1.4%)。经过风险调整后，LOI是与出院后死亡最相关的因素(优势比，6.7；95%可信区间，2.4-19.3)。术后并发症与出院后死亡无明显相关性。结论以患者为中心的结果--独立性丧失和相关性丧失与术后再入院和出院后死亡相关。丧失独立性可以在国家登记中跨多家医院收集。减少LOI的临床举措对于改善老年人的外科护理将是重要的。
IMPORTANCE Older adults are at increased risk for adverse events after surgical procedures. Loss of independence (LOI), defined as a decline in function or mobility, increased care needs at home, or discharge to a nonhome destination, is an important patient-centered outcome measure.OBJECTIVE To evaluate LOI among older adult patients after surgical procedures and examine the association of LOI with readmission and death after discharge in this population.DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined 9972 patients 65 years and older with known baseline function, mobility, and living situation undergoing inpatient operations from January 2014 to December 2014 at 26 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project. A total of 4895 patients were excluded because they were totally dependent, classified as class 5 by the American Society of Anesthesiologists, undergoing orthopedic or spinal procedures, or died prior to discharge.EXPOSURES Loss of independence at time of discharge.MAIN OUTCOMES AND MEASURES Readmission and death after discharge.RESULTS Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge.CONCLUSIONS AND RELEVANCE Loss of independence, a patient-centered outcome, was associated with postoperative readmissions and death after discharge. Loss of independence can feasibly be collected across multiple hospitals in a national registry. Clinical initiatives to minimize LOI will be important for improving surgical care for older adults.