Improving surgical decision-making by measuring and predicting long-term loss of independence after surgery

手术后的生活质量对退伍军人、他们的家人和退伍军人医疗保健至关重要

Quality of life following surgery is critically important to Veterans, their families, and the VA Healthcare System—especially for frail patients who are less likely to be discharged to home, more likely to be readmitted within 30 days, and have substantially increased rates of postoperative mortality and complications. A substantial survival benefit occurs for frail patients when surgeons preoperatively screen for frailty and adjust treatment plans accordingly. Although survival is an important outcome for frail patients, many prioritize quality of life based on preservation of independence. Yet data about long-term independence after surgery is lacking because surgical registries focus on 30-day outcomes and typically do not assess functional status or other more patient-centered quality measures. Discharge rates to skilled nursing facilities after major surgery range from 30% to 40% for frail patients living at home preoperatively, but this is not unexpected as they are likely to benefit from short-term rehabilitation. However, critical knowledge gaps exist regarding (a) whether these patients regain their independence or remain institutionalized; and (b) how to effectively communicate those perioperative risks to support shared decisions about surgical treatment aligned with patients' values. Postoperative Loss of Independence (LOI) is a critically important, but difficult to measure patient-centered outcome, encompassing a broad range of activities important to patients. Here we narrowly define LOI as the number of days living elsewhere than home after presenting from home for the index surgery. LOI may resolve quickly (i.e., short-term LOI) or become protracted/permanent (i.e., long-term LOI). Risk factors for long-term LOI are unknown, but likely include frailty, emergency surgery, and procedures that impose high physiological stress. Prognosis regarding potential LOI is essential for surgeons and patients to make better-informed decisions about surgical treatment that align with patients' goals and values. Specifically, we aim to: Aim 1: Characterize common trajectories of postoperative LOI in the 365 days after surgery to describe clinically meaningful heterogeneity in the patterns of healthcare utilization and their associations with frailty, emergency surgery, and operative stress. In a large Veteran sample, we will quantify the setting and duration of healthcare utilization in the year following surgery, modeling trajectories of LOI and associated risk factors. We hypothesize that LOI will be more common among the frail and after both emergency and high-stress surgery. Aim 2: Adapt the Risk Analysis Index (RAI) to predict long-term LOI and explore alternative models for LOI prediction. The RAI is a 14-item survey measure of surgical frailty that requires 30 seconds to administer at the point-of-care and predicts postoperative mortality and complications. We will adapt the RAI to build, calibrate, and validate models predicting long-term LOI and explore alternative models predicting LOI using variables in the Electronic Health Record and existing risk measures. We hypothesize that item responses from the RAI can accurately predict LOI at the point of care. Aim 3: Explore key stakeholders' perspectives on how LOI risk prognosis might better align shared decisions about surgical treatment with patients' values and goals. We will conduct focus groups with surgeons and semi-structured interviews with patients and their caregivers to explore perspectives on perioperative risks and strategies for aligning shared decisions with patients' values. Research will focus on the factors surgeons, patients, and their informal caregivers consider when making surgical treatment decisions, the relative importance of LOI prognosis in this context, and how the risk of LOI can be best communicated and operationally implemented to inform and improve preference-sensitive surgical choices.