Functional Status and Out-of-Hospital Outcomes in Different Types of Vascular Surgery Patients.

BACKGROUND: We aimed to determine the correlation between the functional status at discharge in non-cardiac vascular surgery patients and the out-of-hospital mortality. METHODS: We performed a retrospective cohort study including adult non-cardiac vascular surgery patients (open, endovascular and venous procedures) surviving hospitalization in Boston, Massachusetts, USA. The exposure of interest was functional status determined by a licensed physical therapist at hospital discharge and rated based on qualitative categories adapted from the Functional Independence Measure. The primary outcome was all cause 90-day mortality after hospital discharge. The secondary outcome was readmission within 30days. Adjusted odds ratios were estimated by multivariable logistic regression models. RESULTS: This cohort included 2318 patients (male 51%; mean age 61 ± 17.7). After evaluation by a physiotherapist, 425 patients scored the lowest functional status, 631 scored moderately low, 681 moderately high and 581 scored the highest functional status. The lowest functional status was associated with a 3.41-fold increased adjusted odds for 90-day mortality (95%CI, 1.70-6.84) compared to patients with the highest functional status. When excluding venous intervention patients, the adjusted odds ratio was 6.76 (95%CI, 2.53-18.12) for the 90-day mortality post-discharge. The adjusted odds for readmission within 30-days was 1.5-fold increase in patients with the lowest functional status (95%CI, 1.04-2.20). CONCLUSIONS: In vascular surgery patients surviving hospitalization, functional status is strongly associated with out-of-hospital mortality and readmission rate. Future trials could provide evidence if improvement of functional status could prevent adverse outcomes in the postoperative setting.

Decreased preoperative functional status is associated with increased mortality following coronary artery bypass graft surgery.

OBJECTIVES: Functional status prior to coronary artery bypass graft surgery may be a risk factor for post-operative adverse events. We sought to examine the association between functional status in the 3 months prior to coronary artery bypass graft surgery and subsequent 180 day mortality. DESIGN, SETTING, AND PARTICIPANTS: We performed a single center retrospective cohort study in 718 adults who received coronary artery bypass graft surgery from 2002 to 2014. EXPOSURES: The exposure of interest was functional status determined within the 3 months preceding coronary artery bypass graft surgery. Functional status was measured and rated by a licensed physical therapist based on qualitative categories adapted from the Functional Independence Measure. MAIN OUTCOMES AND MEASURES: The main outcome was 180-day all-cause mortality. A categorical risk prediction score was derived based on a logistic regression model of the function grades for each assessment. RESULTS: In a logistic regression model adjusted for age, gender, New York Heart Association Class III/IV, chronic lung disease, hypertension, diabetes, cerebrovascular disease, and the Society of Thoracic Surgeons score, the lowest quartile of functional status was associated with an increased odds of 180-day mortality compared to patients with highest quartile of functional status [OR = 4.45 (95%CI 1.35, 14.69; P = 0.014)]. CONCLUSIONS: Lower functional status prior to coronary artery bypass graft surgery is associated with increased 180-day all-cause mortality.

A Pragmatic Preoperative Prediction Score for Nonhome Discharge After Cardiac Operations.

BACKGROUND: Targeted rehabilitation of patients at risk for nonhome discharge (NHD) after an operation is an appealing area for quality improvement. We sought to identify the primary predictors of NHD after cardiac operations to generate a robust preoperative prediction tool for those at greatest risk. METHODS: The medical records of 5,253 patients undergoing cardiac operations between January 1, 2012, and March 31, 2016, were reviewed. Two models of NHD were created: a preoperative model using only preoperative predictors and a postoperative model using the same preoperative predictors and including postoperative adverse outcomes and hospital length of stay. We also determined whether NHD also reduced 30-day hospital readmission. RESULTS: A multivariable logistic regression model allowed robust identification of NHD using only preoperative variables of age, sex, marital status, obesity, comorbidities, addictions, psychiatric disease, and planned operation (area under the curve = 0.820, r2 = 0.349). Postoperative factors associated with NHD, including hospital length of stay and the occurrence of a neurologic event, were included and improved model performance (area under the curve = 0.860, r2 = 0.439), with integrated discrimination improvement of 7.5%. We observed an overall all-cause readmission rate of 12%. Patients with NHD had a higher readmission rate (16% vs 11%; p < 0.0001), as did patients with longer hospital stays, postoperative atrial fibrillation, neurologic event, or infection (all p < 0.0001). CONCLUSIONS: We identified preoperative risk factors for NHD after cardiac operations and developed a pragmatic NHD prediction score with high accuracy. Addition of postoperative risk factors for NHD only modestly improved prediction. NHD does not decrease the readmission rate after cardiac operations.

Functional status, age, and long-term survival after trauma.

BACKGROUND: The association between functional status in trauma survivors and long-term outcomes is unknown. METHODS: We performed an observational cohort study on adult trauma patients (≥18 years), who required admission to the intensive care unit and who survived hospitalization between 1997 and 2011. The exposure of interest was a functional status defined as bed mobility, transfers, and gait level assessed at the time of hospital discharge. Adjusted odds ratios were estimated by multivariable logistic regression models. The primary outcome was all-cause, postdischarge mortality. RESULTS: We analyzed 3,565 patients with a mean (standard deviation) age of 55 (12.4) years; 60% were male, and 78% were white. The 720-day postdischarge mortality was 22.8%. In a logistic regression model, the lowest functional status category at hospital discharge was associated with 4-fold increased odds of 720-day postdischarge mortality (adjusted odds ratio 4.06 (95% confidence interval, 2.65-6.20, P < .001) compared with patients with independent functional status. We compared the odds of 720-day postdischarge mortality in patients with independent functional status and in patients in the lowest functional status category at hospital discharge. The odds of 720-day postdischarge mortality were stronger in older adults (≥65 years: adjusted odds ratio 3.34 [95% confidence interval, 1.72-6.50, P < .001]) than in younger adults (<65 years: adjusted odds ratio 2.53 [95% confidence interval, 1.39-4.60, P = .002]). Finally, improvement of functional status prior to discharge was associated with a 52% decrease in the odds of 720-day postdischarge mortality (adjusted odds ratio 0.48; 95% confidence interval, 0.30-0.75; P < .001) compared with patients without a change in functional status prior to discharge. CONCLUSION: In trauma intensive care unit survivors, functional status at hospital discharge is predictive of long-term mortality.

Functional Status in ICU Survivors and Out of Hospital Outcomes: A Cohort Study.

OBJECTIVES: Functional status at hospital discharge may be a risk factor for adverse events among survivors of critical illness. We sought to examine the association between functional status at hospital discharge in survivors of critical care and risk of 90-day all-cause mortality after hospital discharge. DESIGN: Single-center retrospective cohort study. SETTING: Academic Medical Center. PATIENTS: Ten thousand three hundred forty-three adults who received critical care from 1997 to 2011 and survived hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The exposure of interest was functional status determined at hospital discharge by a licensed physical therapist and rated based on qualitative categories adapted from the Functional Independence Measure. The main outcome was 90-day post hospital discharge all-cause mortality. A categorical risk-prediction score was derived and validated based on a logistic regression model of the function grades for each assessment. In an adjusted logistic regression model, the lowest quartile of functional status at hospital discharge was associated with an increased odds of 90-day postdischarge mortality compared with patients with independent functional status (odds ratio, 7.63 [95% CI, 3.83-15.22; p < 0.001]). In patients who had at least 7 days of physical therapy treatment prior to hospital discharge (n = 2,293), the adjusted odds of 90-day postdischarge mortality in patients with marked improvement in functional status at discharge was 64% less than patients with no change in functional status (odds ratio, 0.36 [95% CI, 0.24-0.53]; p < 0.001). CONCLUSIONS: Lower functional status at hospital discharge in survivors of critical illness is associated with increased postdischarge mortality. Furthermore, patients whose functional status improves before discharge have decreased odds of postdischarge mortality.