Alive and at home: Five-year outcomes in older adults following emergency general surgery

Abstract

BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship. METHODS We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models. RESULTS A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17–5.11). CONCLUSION Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period. LEVEL OF EVIDENCE Epidemiological, level III.

Not all is lost: Functional recovery in older adults following emergency general surgery

“…Monitoring need not take place in a surgeon’s office, and may be better carried out by primary care providers with an ongoing relationship with the patient. Providers should pay particular attention to patients with high-risk prognostic features for functional decline, including advanced age, frailty, low socioeconomic status, and high-risk diagnoses 4,52,53 …”

“…These categories have been used in previous work associated with this study cohort and are based on strata of in-hospital mortality. 4 All analyses were performed using SAS software (version 9.4; SAS Institute Inc., Cary, North Carolina) and R Statistical Software (version 3.5.1; R Foundation for Statistical Computing, Vienna, Austria). Two-sided p values less than 0.05 were considered statistically significant.…”

“…The model was refit separately in the subgroup of patients who underwent surgery, those who were managed nonoperatively, and among patients who were admitted with low-risk (appendicitis, cholecystitis), intermediate-risk (diverticulitis, hernia with obstruction and/or strangulation, bowel obstruction), and high-risk (peptic ulcer disease, intestinal ischemia, perforated viscus) EGS diagnosis. These categories have been used in previous work associated with this study cohort and are based on strata of in-hospital mortality 4 …”

“…This cohort has been previously described. 4 In brief, we identified all older adults (age ≥65 years) admitted to any hospital in Ontario between April 1, 2006, andMarch 31, 2016, for one of eight EGS conditions: appendicitis, cholecystitis, diverticulitis, hernia with obstruction and/or strangulation, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus. These diagnoses represent common EGS diseases with a high burden of hospital admission, surgical intervention, morbidity, and mortality.…”

“…While older EGS patients are at a higher risk of functional decline and nursing home admission in the years immediately following hospitalization compared with those without such a hospitalization, the trajectory of functional decline in these patients is not known. 4 Data from the critical care literature suggest that functional status in older hospital survivors may wax and wane over prolonged periods. [19][20][21] If present, periods of fluctuation in function following EGS admission may represent opportunities to intervene to prevent further decline.…”