Association of frailty with days alive at home after cardiac surgery: a population-based cohort study

Abstract

Background: Frailty is a geriatric syndrome that leaves people vulnerable to adverse outcomes. In cardiac surgery, minimal data describe associations between frailty and patient-centred outcomes. Our objective was to estimate the association between frailty and days alive at home after cardiac surgery. Methods: We conducted a population-based cohort study using linked health administrative data in the Canadian province of Ontario. All individuals >65 yr at the time of cardiac surgery were assigned a frailty score using a validated frailty index. Days alive and at home in the 30 and 365 days after surgery were calculated. The unadjusted and adjusted associations between frailty and days alive at home were calculated. Results: We identified 61 389 patients from 2009 to 2015. Frailty was associated with reduced days at home within 30 days (adjusted ratio of means for every 10% increase in frailty¼0.79; 95% confidence interval [CI], 0.78e0.81; P<0.0001) and 365 days (adjusted ratio of means for every 10% increase in frailty¼0.92; 95% CI, 0.91e0.93; P<0.0001) of surgery. Results were consistent in sensitivity analyses (5.0 fewer days alive at home [95% CI, 4.8e5.2] within 30 days and 9.0 fewer days alive at home [95% CI, 8.7e9.2] within 365 days after surgery). Conclusion: Frailty is associated with a reduction in days alive at home after major cardiac surgery. This information should be considered in prognostic discussions before surgery and in care planning for vulnerable older patient groups. Days alive at home may be a useful outcome for routine measurement in quality, reporting, and studies using routinely collected data.

Heart, home, and frailty: new risk scores and outcomes for cardiac surgery patients

“…11 In their study, McIsaac and colleagues examined the association of patient frailty, measured via a preoperative frailty index (pFI), with DAH after major cardiac surgery. 4 Among 61 000 patients, each 10% increase in the frailty index was associated with a 2.4-day decrease in adjusted median DAH in the first month, and a 4.3-day decrease in the first year after surgery. Mediation analyses were also performed, which helped delineate the relative contributors to this reduction in DAH.…”

“…2 For cardiac surgical patients with frailty, these risks are magnified even further. 3 In this issue of the British Journal of Anaesthesia, McIsaac and colleagues 4 report on the association between patient frailty and the outcome of days alive and at home after major cardiac surgery. This paper raises important points around measuring frailty, and identifying outcomes that are important to patients, their families, and the broader health system.…”

“…After a systematic review and Delphi process, the Standardised Endpoints in Perioperative Medicine (StEP) Consensus group recommended days alive at home (DAH) as a valid patient-centred outcome. 9 DAH integrates length of hospital stay, duration of any readmission, and mortality over time, 4,10,11 typically 30 days after surgery: DAH-30. This is a 'more is better' metric with a skewed distribution, with the point estimate usually expressed as a median.…”

“…Further, McIsaac and colleagues examined time in subacute care, which is an important consideration for vulnerable patients. 4 Another metric related to DAH is days alive and out of hospital, 10 which only includes acute hospital care; therefore, a patient admitted to rehabilitation would be regarded as out-of-hospital, but is not at home. From a patient perspective, DAH is likely to be a more valuable metric, and has been validated in older adults (>70 yr old) after surgery, 12 but is harder to measure accurately.…”

“…24 This study by McIsaac and colleagues adds to our understanding of how frailty affects one very important QoL measure: time spent at home after surgery. 4 Further research is required to inform how frailty influences the other relevant postoperative patient-centred endpoints identified by the StEP group: patient satisfaction, health-related QoL, functional status, and life-impact measures. 9 A further consideration when assessing the importance of DAH is whether patients were living in their own home before surgery.…”