Dataset Information

Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.

ABSTRACT:

Importance

Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.

Objective

To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications.

Design, setting, and participants

In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417?840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS?=?0) and those with a LOS of 1 or more days (LOS???1). Statistical analysis was performed from June 1, 2018, to March 31, 2019.

Exposure

Frailty, as measured by the Risk Analysis Index.

Main outcomes and measures

The main outcome was 30-day unplanned readmission.

Results

Of the 417?840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS?=?0, 2.0%; LOS???1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS?=?0, 8.3% vs 1.9%; LOS???1, 8.5% vs 3.2%; P?Conclusions and relevanceThese findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.

SUBMITTER: Rothenberg KA

PROVIDER: S-EPMC6632151 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.

Rothenberg Kara A KA Stern Jordan R JR George Elizabeth L EL Trickey Amber W AW Morris Arden M AM Hall Daniel E DE Johanning Jason M JM Hawn Mary T MT Arya Shipra S

JAMA network open 20190503 5

<h4>Importance</h4>Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures.<h4>Objective</h4>To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical comp ...[more]

PMID: 31125103

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Project description:BackgroundLimitations exist in available studies investigating effect of preoperative frailty on postoperative outcomes. This study was designed to analyze the association between composite risk index, an accumulation of preoperative frailty deficits, and the risk of postoperative complications in older patients recovering from elective digestive tract surgery.MethodsThis was a retrospective cohort study. Baseline and perioperative data of older patients (age ≥ 65 years) who underwent elective digestive tract surgery from January 1, 2017 to December 31, 2018 were collected. The severity of frailty was assessed with the composite risk index, a composite of frailty deficits including modified frailty index. The primary endpoint was the occurrence of postoperative complications during hospital stay. The association between the composite risk index and the risk of postoperative complications was assessed with a multivariable logistic regression model.ResultsA total of 923 patients were included. Of these, 27.8% (257) developed postoperative complications. Four frailty deficits, i.e., modified frailty index ≥0.27, malnutrition, hemoglobin < 90 g/L, and albumin ≤30 g/L, were combined to generate a composite risk index. Multivariable analysis showed that, when compared with patients with composite risk index of 0, the odds ratios (95% confidence intervals) were 2.408 (1.714-3.383, P < 0.001) for those with a composite risk index of 1, 3.235 (1.985-5.272, P < 0.001) for those with a composite risk index of 2, and 9.227 (3.568-23.86, P < 0.001) for those with composite risk index of 3 or above. The area under receiver-operator characteristic curve to predict postoperative complications was 0.653 (95% confidence interval 0.613-0.694, P < 0.001) for composite risk index compared with 0.622 (0.581-0.663, P < 0.001) for modified frailty index.ConclusionFor older patients following elective digestive tract surgery, high preoperative composite risk index, a combination of frailty deficits, was independently associated with an increased risk of postoperative complications.

Project description:ImportancePreoperative hyperglycemia is associated with adverse postoperative outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c (HbA1c) or postoperative glucose levels are more useful in predicting adverse events following surgery is uncertain in the current literature.ObjectiveTo examine the use of preoperative HbA1c and early postoperative glucose levels for predicting postoperative complications and readmission.Design, setting, and participantsIn this observational cohort study, inpatient gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to 2014 were identified, and cases of known infection within 3 days before surgery were excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable (<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications and readmissions with the closest preoperative HbA1c within 90 days and the highest postoperative glucose levels within 48 hours of undergoing surgery.Main outcomes and measuresPostoperative complications and 30-day unplanned readmission following discharge.ResultsOf 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7 (10.6) years. The cohort included 23 094 operations with measurements of preoperative HbA1c levels and postoperative glucose levels. The complication and 30-day readmission rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c, postoperative glucose levels, postoperative insulin use, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), and other patient and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an HbA1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative HbA1c of more than 6.5% had lower thresholds for postoperative insulin use.Conclusions and relevanceEarly postoperative hyperglycemia was associated with increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c was associated with increased postoperative glucose level checks and insulin use, suggesting that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may explain this finding.

Project description:IntroductionDiabetes has an increasing worldwide prevalence. It is known to be a predisposing factor for postoperative complications. Preoperative glycaemic control strategies should be pursued as glycaemic control could serve as a modifiable risk factor. Glycated haemoglobin (HbA1c), a marker of 3-month average glycaemic control, has been shown in meta-analyses to predict postoperative complications in cardiothoracic, bariatric and orthopaedic surgery. However, there is no meta-analysis in the major abdominal surgery population, in whom morbidity may be higher due to the nature of the surgery. Understanding the association between HbA1c and postoperative complications could help in preoperative risk prognostication, counselling and glycaemic target selection. The aim of this systematic review and meta-analysis is to evaluate all evidence on the association between preoperative HbA1c and postoperative complications in elective major abdominal surgery, and to investigate the threshold HbA1c level before postoperative complication rates increase.Methods and analysisThis review will be performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure will be searched for all original studies. Study selection, data extraction, risk of bias and quality assessment will be conducted by two independent reviewers. The primary outcome is the association between preoperative HbA1c and major postoperative complications (Clavien Dindo 3-5), and the secondary outcome is the association between HbA1c and overall postoperative complications. Data management and synthesis will be performed using Microsoft Excel and Stata to derive pool estimates.Ethics and disseminationNo ethics approval is required as only secondary data will be used. Findings will be disseminated through peer-reviewed journals and conference presentations.Prospero registration numberCRD42020167347.

Project description:BackgroundAs an effort to reduce hospital readmissions, early follow-up visits were recommended by the Society of Hospital Medicine. However, published literature on the effect of follow-up visits is limited with mixed conclusions. Our goal here is to fully explore the relationship between follow-up visits and the all-cause non-elective 30-day readmission rate (RR) after adjusting for confounders.Methods and resultsTo conduct this retrospective observational study, we extracted data for 55,378 adult inpatients from Advocate Health Care, a large, multi-hospital system serving a diverse population in a major metropolitan area. These patients were discharged to Home or Home with Home Health services between June 1, 2013 and April 30, 2015. Our findings from time-dependent Cox proportional hazard models showed that follow-up visits were significantly associated with a reduced RR (adjusted hazard ratio: 0.86; 95% CI: 0.82-0.91), but in a complicated way because the interaction between follow-up visits and a readmission risk score was significant with p-value < 0.001. Our analysis using logistic models on an adjusted data set confirmed the above findings with the following additional results. First, time matter. Follow-up visits within 2 days were associated with the greatest reduction in RR (adjusted odds ratio: 0.72; 95% CI: 0.63-0.83). Visits beyond 2 days were also associated with a reduction in RR, but the strength of the effect decreased as the time between discharge and follow-up visit increased. Second, the strength of such association varied for patients with different readmission risk scores. Patients with a risk score of 0.113, high but not extremely high risk, had the greatest reduction in RR from follow-up visits. Patients with an extremely high risk score (> 0.334) saw no RR reduction from follow-up visits. Third, a patient was much more likely to have a 2-day follow-up visit if that visit was scheduled before the patient was discharged from the hospital (30% versus < 5%).ConclusionsFollow-up visits are associated with a reduction in readmission risk. The timing of follow-up visits can be important: beyond two days, the earlier, the better. The effect of follow-up visits is more significant for patients with a high but not extremely high risk of readmission.

Project description:BackgroundThe COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.MethodsThis prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/-]) or negative throughout (COVID[-/-]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.ResultsBetween March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[-/-] to be 8.4 (C.I. 4.9-14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.DiscussionDespite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.

Project description:ImportanceThe Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery.ObjectiveTo assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).Design, setting, and participantsThis multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019.ExposuresTotal hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not.Main outcomes and measuresThe primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality.ResultsDuring the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P?=?.22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P?=?.02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P?<?.001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P?<?.001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P?<?.001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P?<?.001).Conclusions and relevanceAn increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

Dataset Information

Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.

Importance

Objective

Design, setting, and participants

Exposure

Main outcomes and measures

Results

Publications

Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.

Similar Datasets

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