Dataset Information

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease.

ABSTRACT:

Objectives

To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans.

Design

Retrospective analysis of claims data.

Setting

US communities with Medicare beneficiaries.

Participants

Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra-abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319).

Measurements

Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long-term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community-dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan-Meier plots, and χ² tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community-dwelling status at 9 months.

Results

A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in-hospital complications. Overall, 418 (14.3%) HA-EGS survivors died during the follow-up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA-EGS.

Conclusion

Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA-EGS. Long-term expectations after surviving HA-EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality-of-life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289-2297, 2019.

SUBMITTER: Smith JW

PROVIDER: S-EPMC6861609 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease.

Smith Jason W JW Knight Davis Jennifer J Quatman-Yates Catherine C CC Waterman Brittany L BL Strassels Scott A SA Wong Jen D JD Heh Victor K VK Baselice Holly E HE Brock Guy N GN Clark Brian C BC Bridges John F P JFP Santry Heena P HP

Journal of the American Geriatrics Society 20190713 11

<h4>Objectives</h4>To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans.<h4>Design</h4>Retrospective analysis of claims data.<h4>Setting</h4>US communities with Medicare beneficiaries.<h4>Participants</h4>Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ thre ...[more]

PMID: 31301180

Similar Datasets

Project description:IntroductionTransferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database.MethodsWe identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design.ResultsWe identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay.ConclusionsEGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.

Project description:Study objectivesThe objective of this study was to determine if there is a proximity effect of high-acuity, pediatric-capable emergency departments (EDs) on the weighted pediatric readiness score of neighboring general EDs and whether this effect is attributable to specific components of the National Pediatric Readiness Guidelines.MethodsPediatric readiness was assessed using the weighted pediatric readiness score of EDs based on the 2013 National Pediatric Readiness Project assessment. High-acuity, pediatric-capable EDs were defined as those with a separate pediatric ED and inpatient pediatric services, including the following: pediatric ICU, pediatric ward, and neonatal ICU. Neighboring general EDs are within a 30-minute drive time of a high-acuity, pediatric-capable ED. Analysis was stratified by annual ED pediatric volume: low (<1800), medium (1800-4999), medium-high (5000-9999), and high (>10,000). We analyzed components of the readiness guidelines, including quality improvement/safety initiatives, pediatric emergency care coordinators, and availability of pediatric-specific equipment. Groups were compared using chi-squared or Wilcoxon rank-sum test with P values <0.05 considered significant.ResultsOf the 4149 surveyed hospitals, 3933 general EDs (not high-acuity, pediatric-capable EDs) were identified, of which 1009 were located within a 30-minute drive to a high-acuity, pediatric-capable ED. Neighboring general EDs had a statistically significantly higher median weighted pediatric readiness score across pediatric volumes (weighted pediatric readiness score 76.3 vs 65.3; P < 0.001). Neighboring general EDs were more likely to have a pediatric emergency care coordinator, a notification policy for abnormal pediatric vital signs, and >90% of pediatric-specific equipment.ConclusionsWe found neighboring general EDs have a higher level of pediatric readiness as measured by the median weighted pediatric readiness score. High-acuity, pediatric-capable EDs may influence the pediatric readiness of neighboring general Eds, but further investigation is needed to clarify target areas for outreach by state and national partners to improve overall pediatric readiness.

Project description:BackgroundAlthough nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.MethodsWe used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.ResultsOf 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.ConclusionPatients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Project description:ObjectiveAdvance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors.MethodsIn this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs.ResultsAmong 562 community-dwelling stroke survivors who entered the survey after screening questions confirmed eligibility, 421 (74.9%) completed survey components with relevant variables of interest. The median age was 69 years (IQR 58-75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to stroke survivors without ADs, those with ADs were more likely to be older (median age 72 vs. 61 years; p<0.001), White (91.2% vs. 75.9%, p<0.001), and male (58.6% vs. 46.5%, p = 0.015), and reported higher education (p<0.001) and income (p = 0.011). Ninety-eight (23.3%) participants had "never heard of palliative care". Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5-12] vs. 7 [IQR 0-11], p<0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18-28] vs. 29 [IQR 24-35], p<0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30-2.02; p<0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04-2.86; p = 0.034), PaCKS scores (OR 1.06 per 1 point increase, 95% CI 1.01-1.12; p = 0.018), and Attitudes Towards Life-Sustaining Treatments Scale scores (OR 0.91 per 1 point increase, 95% CI 0.88-0.95; p<0.001) as variables independently associated with ADs.ConclusionsAge, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs.

Project description:ImportanceThere is growing interest in developing coordinated regional systems for nontraumatic surgical emergencies; however, our understanding of existing emergency general surgery (EGS) care communities is limited.ObjectiveTo apply network analysis methods to delineate EGS care regions and compare the performance of this method with the Dartmouth Health Referral Regions (HRRs).Design, setting, and participantsThis cross-sectional study was conducted using the 2019 California and New York state emergency department and inpatient databases. Eligible participants included all adult patients with a nonelective admission for common EGS conditions. Interhospital transfers (IHTs) were identified by transfer indicators or temporally adjacent hospitalizations at 2 different facilities. Data analysis was conducted from January to May 2024.ExposureAdmission for primary EGS diagnosis.Main outcomes and measuresRegional EGS networks (RENs) were delineated by modularity optimization (MO), a community detection method, and compared with the plurality-based Dartmouth HRRs. Geographic boundaries were compared through visualization of patient flows and associated health care regions. Spatial accuracy of the 2 methods was compared using 6 common network analysis measures: localization index (LI), market share index (MSI), net patient flow, connectivity, compactness, and modularity.ResultsA total of 1 244 868 participants (median [IQR] age, 55 [37-70 years]; 776 725 male [62.40%]) were admitted with a primary EGS diagnosis. In New York, there were 405 493 EGS encounters with 3212 IHTs (0.79%), and 9 RENs were detected using MO compared with 10 Dartmouth HRRs. In California, there were 839 375 encounters with 10 037 IHTs (1.20%), and 14 RENs were detected compared with 24 HRRs. The greatest discrepancy between REN and HRR boundaries was in rural regions where one REN often encompassed multiple HRRs. The MO method was significantly better than HRRs in identifying care networks that accurately captured patients living within the geographic region as indicated by the LI and MSI for New York (mean [SD] LI, 0.86 [1.00] for REN vs 0.74 [1.00] for HRR; mean [SD] MSI, 0.16 [0.13] for REN vs 0.32 [0.21] for HRR) and California (mean [SD] LI, 0.83 [1.00] for REN vs 0.74 [1.00] for HRR; mean [SD] MSI, 0.19 [0.14] for REN vs 0.39 [0.43] for HRR). Nearly 27% of New York hospitals (37 of 139 hospitals [26.62%]) and 15% of California hospitals (48 of 336 hospitals [14.29%]) were reclassified into a different community with the MO method.Conclusions and relevanceDevelopment of optimal health delivery systems for EGS patients will require knowledge of care patterns specific to this population. The findings of this cross-sectional study suggest that network science methods, such as MO, offer opportunities to identify empirical EGS care regions that outperform HRRs and can be applied in the development of coordinated regional systems of care.

Project description:BackgroundSocioeconomic disadvantage is associated with worse outcomes after elective surgery, but the effect on emergency general surgery (EGS) remains unclear. We examined the association of socioeconomic disadvantage and outcomes after EGS procedures and investigated whether admission to hospitals with comprehensive clinical and social resources mitigated this effect.MethodsAdults undergoing 1 of the 10 most burdensome high- and low-risk EGS procedures were identified in six 2014 State Inpatient Databases. Socioeconomic disadvantage was assessed using Area Deprivation Index (ADI) of patient residence. Multivariable logistic regression models adjusting for patient and hospital factors were used to evaluate the association between ADI quartile (high >75 percentile vs. low <25 percentile), and 30-day readmission, in-hospital mortality, and discharge disposition. Effect modification between ADI and (a) level 1 trauma center and (b) safety-net hospital status was tested.ResultsA total of 103,749 patients were analyzed: 72,711 low-risk (70.1%) and 31,038 high-risk procedures (29.9%). Patients from neighborhoods with high socioeconomic disadvantage had a higher proportion with ≥3 comorbidities (41.9% vs. 32.0%), minority race/ethnicity (66.3% vs. 42.4%), and Medicaid (28.8% vs. 14.7%) and were less likely to be treated at level 1 trauma centers (18.3% vs. 27.7%; p < 0.001 for all). Adjusting for competing factors, high socioeconomic disadvantage was associated with increased in-hospital mortality after high-risk procedures (odd ratio, 1.30; 95% confidence interval, 1.01-1.66; p = 0.04) and higher odds of non-home discharge (odd ratio, 1.15; 95% confidence interval, 1.02-1.30; p = 0.03) for low-risk procedures. Socioeconomic disadvantage was not associated with 30-day readmission for either procedure group. Level 1 trauma status and safety-net hospital did not meaningfully mitigate effect of ADI for any outcome.ConclusionSocioeconomic disadvantage is associated with increased mortality after high-risk procedures and higher odds of non-home discharge after low-risk procedures. This effect was not mitigated by either level 1 trauma or safety-net hospitals. Interventions that specifically address the needs of socially vulnerable communities will be required to significantly improve EGS outcomes for this population.Level of evidencePrognostic and Epidemiologic, level III.

Dataset Information

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease.

Objectives

Design

Setting

Participants

Measurements

Results

Conclusion

Publications

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets