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.

Keywords: community-dwelling status; emergency general surgery; quality of life.

Figure 1.

Kaplan-Meier Curve Modeling Time to Death By Discharge Disposition¹ Among Medicare Beneficiaries Age 65 and older Hospitalized in the First 3 months of 2015 with High-Acuity Emergency General Surgery Disease who Survived to Discharge (N = 2922) 1. Excludes those who died during index hospitalization (N = 273), were discharged to hospice (N = 81), or had an other/unknown discharge disposition (N =43). 2. Long-term acute care facility includes a Medicaid facilities and intermediate care facilities