Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study.

INTRODUCTION: Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively. METHODS: EGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal-Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models. RESULTS: Among 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001). CONCLUSIONS: HFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.

An evaluation of the outcome metric 'days alive and at home' in older patients after hip fracture surgery.

'Days alive and at home' is a validated measure that estimates the time spent at home, defined as the place of residence before admission to hospital. We evaluated this metric in older adults after hip fracture surgery and assessed two follow-up durations, 30 and 90 days. Patients aged ≥ 70 years who underwent hip fracture surgery were identified retrospectively via hospital admission and government mortality records. Patients who successfully returned home and were still alive within 90 days of surgery were distinguished from those who were not. Regression models were used to examine which variables were associated with failure to return home and number of days at home among those who did return, within 90 days of surgery. We analysed the records of 825 patients. Median (IQR [range]) number of days at home within 90 days (n = 788) was 54 (0-76 [0-88]) days and within 30 days (n = 797) it was 2 (0-21 [0-28]) days. Out of these, 274 (35%) patients did not return home within 90 days and 374 (47%) within 30 days after surgery. Known peri-operative risk-factors such as older age, pre-operative anaemia and postoperative acute renal impairment were associated with failure to return home. This study supports days alive and at home as a useful patient-centred outcome measure in older adults after hip fracture surgery. We recommend that this metric should be used in clinical trials and measured at 90, rather than 30, postoperative days. As nearly half of this patient population did not return home within 30 days, the shorter time-period catches fewer meaningful events.

Impact of perioperative inflammation on days alive and at home after surgery.

Background: Perioperative inflammation is associated with perioperative complications, including delirium, that are associated with a reduced number of postoperative days alive and at home at 90 days (DAH90). We tested whether inflammation was associated with DAH90 even when adjusting for perioperative factors, and whether inflammation independently was associated with DAH90 when adjusting for delirium. Methods: We conducted a prospective cohort study of major, non-intracranial surgical patients who were older than 65 yr (n=134). We measured postoperative delirium incidence and severity, and changes in interleukin (IL)-8 and IL-10 in blood plasma. Our primary outcome, DAH90, was analysed using quantile regression. Results: Before adjusting for delirium, a postoperative day 1 increased IL-8 was associated with fewer DAH90 at the 0.75 quantile (ß=-0.082; 95% confidence interval [CI], -0.19 to -0.006) after adjusting for demographic (age and sex) and perioperative factors (cardiovascular surgery, National Surgical Quality Improvement Program risk of death, and operative time). IL-10 was similarly associated with DAH90 at the 0.5 (ß=-0.026; 95% CI, -0.19 to -0.001) and 0.75 (ß= -0.035; 95% CI, -0.07 to -0.006) quantiles. Neither cytokine was significantly associated with DAH90 once delirium and baseline Trail Making Test B were added to the models. Conclusions: Perioperative inflammation predicts DAH90, but when delirium is added to the model inflammation loses significance as a predictor, whereas delirium is significant. Targeting perioperative inflammation may reduce delirium and moderate hospital readmission and mortality. Clinical trial registration: NCT03124303.

Assessing the concurrent validity of days alive and at home metric.

BACKGROUND: Most patients living with serious illness value spending time at home. Emerging data suggest that days alive and at home (DAH) may be a useful metric, however more research is needed. We aimed to assess the concurrent validity of DAH with respect to clinically significant changes in patient- and caregiver-reported outcomes (PROs). METHODS: We drew data from a study that compared two models of home-based palliative care among seriously ill patients and their caregivers in two Kaiser Permanente regions (Southern California and Northwest). We included participants aged 18 years or older (n = 3533) and corresponding caregivers (n = 463). We categorized patients and caregivers into three groups based on whether symptom burden (Edmonton Symptom Assessment System, ESAS) or caregiving preparedness (Preparedness for Caregiving Scale, CPS) showed improvements, deterioration, or no change from baseline to 1 month later. We measured DAH across four time windows: 30, 60, 90, and 180 days, after admission to home palliative care. We used two-way ANOVA to compare DAH across the PRO groups. RESULTS: Adjusted pairwise comparisons showed that DAH was highest for patients whose ESAS scores improved or did not change compared with those with worsening symptoms. Although the mean differences ranged from less than a day to about 3 weeks, none exceeded 0.3 standard deviations. ESAS change scores had weak negative correlations (r = -0.11 to -0.21) with DAH measures. CPS change scores also showed weak, positive correlations (r = 0.23-0.24) with DAH measures. CONCLUSION: DAH measures are associated, albeit weakly, with clinically important improvement or maintenance of patient symptom burden in a diverse, seriously ill population.