The impact of delayed mobilization on post-discharge outcomes after emergency abdominal surgery: A prospective cohort study in older patients.

Surgeons are increasingly treating seniors with complex care needs who are at high-risk of readmission and functional decline. Yet, the prognostic importance of post-operative mobilization in older surgical patients is under-investigated and remains unclear. Thus, we evaluated the relationship between post-operative mobilization and events after hospital discharge in older people. Overall, 306 survivors of emergency abdominal surgery aged ≥65y who required help with <3 activities of daily living were prospectively followed at two Canadian tertiary-care hospitals. Time until mobilization after surgery was attained from hospital charts and a priori defined as 'delayed' (≥36h) or 'early' (<36h). Primary outcomes for 30-day and 6-month all-cause readmission/death after discharge were assessed in multivariable logistic regression. Patients had a mean age of 76 ± 7.7 years, 45% were women, 41% were 'vulnerable-to-moderately-frail', according to the Clinical Frailty Scale. Most common reasons for admission were gallstones (23%), intestinal obstructions (21%), and hernia (17%). Median time to post-operative mobilization was 19h (interquartile range 9-35); 74 (24%) patients had delayed mobilization. Delayed mobilization was independently associated with higher risk of 30-day readmission/death (19 [26%] vs. 22 [10%], P<0.001; adjusted odds ratio [aOR] 2.24, 95%CI 0.99-5.06, P = 0.05), but this was not statistically significant at 6-months (38 [51%] vs. 64 [28%], P<0.001; aOR 1.72, 95%CI 0.91-3.25, P = 0.1). One-quarter of older surgical patients stayed in bed for 1.5 days post-operatively. Delayed mobilization was associated with increased risk of short-term readmission/death. As older, more frail patients undergo surgery, mobilization of older surgical patients remains an understudied post-operative factor. Trial registration: clinicaltrials.gov identifier: NCT02233153.

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study.

BACKGROUND: Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients. METHODS: We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression. RESULTS: Of 308 patients (median age 75 [range 65-94] yr, median Clinical Frailty Score 3 [range 1-6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (n = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29-16.45) and frail patients (n = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13-17.94) than among patients who were well (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well. INTERPRETATION: Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission. TRIAL REGISTRATION FOR PRIMARY STUDY: ClinicalTrials.gov, no. NCT02233153.

Analysis of postdischarge costs following emergent general surgery in elderly patients.

BACKGROUND: As populations age, more elderly patients will undergo surgery. Frailty and complications are considered to increase in-hospital cost in older adults, but little is known on costs following discharge, particularly those borne by the patient. We examined risk factors for increased cost and the type of costs accrued following discharge in elderly surgical patients. METHODS: Acute abdominal surgery patients aged 65 years and older were prospectively enrolled. We assessed baseline clinical characteristics, including Clinical Frailty Scale (CFS) scores. We calculated 6-month cost (in Canadian dollars) from patient-reported use following discharge according to the validated Health Resource Utilization Inventory. Primary outcomes were 6-month overall cost and cost for health care services, medical products and lost productive hours. Outcomes were log-transformed and assessed in multivariable generalized linear and zero-inflated negative binomial regressions and can be interpreted as adjusted ratios (AR). Complications were assessed according to Clavien-Dindo classification. RESULTS: We included 150 patients (mean age 75.5 ± 7.6 yr; 54.1% men) in our analysis; 10.8% had major and 43.2% had minor complications postoperatively. The median 6-month overall cost was $496 (interquartile range $140-$1948). Disaggregated by cost type, frailty independently predicted increasing costs of health care services (AR 1.76, 95% confidence interval [CI] 1.43-2.18, p < 0.001) and medical products (AR 1.61, 95% CI 1.15-2.25, p = 0.005), but decreasing costs in lost productive hours (AR 0.39, p = 0.002). Complications did not predict increased cost. CONCLUSION: Frail patients accrued higher health care services and product costs, but lower costs from lost productive hours. Interventions in elderly surgical patients should consider patient-borne cost in older adults and lost productivity in less frail patients. TRIAL REGISTRATION: NCT02233153 (clinicaltrials.gov).

CONTEXTE: Avec le vieillissement de la population, les personnes âgées seront plus nombreuses à subir des chirurgies. Il est déjà reconnu que la fragilité et les complications font augmenter les coûts d'hospitalisation chez les adultes âgés, mais on en sait relativement peu sur les coûts posthospitaliers, particulièrement ceux assumés par le patient lui-même. Nous avons analysé les facteurs de risque d'augmentation de ces coûts et les types de dépenses assumées après le congé par les patients âgés opérés. MÉTHODES: Pour l'étude, nous avons recruté des patients de 65 ans et plus qui allaient subir une chirurgie abdominale d'urgence. Nous avons déterminé leurs caractéristiques cliniques initiales, y compris leur score à l'échelle de fragilité clinique (EFC). Nous avons calculé les coûts échelonnés sur 6 mois (en dollars canadiens) rapportés par les patients après leur congé, selon un inventaire validé de l'utilisation des ressources de santé. Les paramètres principaux étaient le montant total des dépenses et le coût des services de santé, des produits médicaux et des heures de travail perdues pour une période de 6 mois. Une transformation logarithmique a été appliquée aux données, qui ont été évaluées par une analyse de régression linéaire multivariée généralisée et par une analyse binomiale négative avec surreprésentation des zéros. Les résultats peuvent être interprétés comme des rapports ajustés (RA). Les complications ont été évaluées selon la classification de Clavien-Dindo. RÉSULTATS: Nous avons inclus 150 patients dans notre analyse (âge moyen : 75,5 ± 7,6 ans; proportion d'hommes : 54,1 %). Après l'opération, 10,8 % ont présenté des complications majeures, et 43,2 %, des complications mineures. Le montant total médian des dépenses sur 6 mois était de 496 $ (éventail interquartile : 140-1948 $). Dans des analyses effectuées selon le type de dépenses, la fragilité était une variable explicative permettant de prédire indépendamment l'accroissement des coûts des services de santé (RA : 1,76; intervalle de confiance [IC] à 95 % : 1,43-2,18; p < 0,001) et des produits médicaux (RA : 1,61; IC à 95 % : 1,15-2,25; p = 0,005) ainsi que la réduction des coûts associés aux heures de travail perdues (RA : 0,39; p = 0,002). Les complications n'avaient pas de valeur prédictive en ce qui a trait à l'accroissement des coûts. CONCLUSION: Les patients fragiles ont assumé des coûts plus élevés en services de santé et en produits médicaux, mais des coûts moindres en lien avec la perte d'heures de travail. Les interventions chez les patients en chirurgie âgés devraient tenir compte des coûts assumés par cette population et de la perte de productivité chez les patients moins fragiles. ENREGISTREMENTDEL'ESSAI: ClinicalTrials.gov, no NCT02233153.

Depressive symptoms are associated with higher rates of readmission or mortality after medical hospitalization: A systematic review and meta-analysis.

Depressive symptoms during a medical hospitalization may be an overlooked prognostic factor for adverse events postdischarge. Our aim was to evaluate whether depressive symptoms predict 30-day readmission or death after medical hospitalization. We conducted a systematic review of studies that compared postdischarge outcomes by in-hospital depressive status. We assessed study quality and pooled published and unpublished data using random effects models. Overall, one-third of 6104 patients discharged from medical wards were depressed (interquartile range, 27%-40%). Compared to inpatients without depression, those discharged with depressive symptoms were more likely to be readmitted (20.4% vs 13.7%, risk ratio [RR]: 1.73, 95% confidence interval [CI]: 1.16-2.58) or die (2.8% vs 1.5%, RR: 2.13, 95% CI: 1.31-3.44) within 30 days. Depressive symptoms were common in medical inpatients and are associated with an increased risk of adverse events postdischarge. Journal of Hospital Medicine 2016;11:373-380. © 2016 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine.

Current depressive symptoms but not history of depression predict hospital readmission or death after discharge from medical wards: a multisite prospective cohort study.

OBJECTIVE: Although death or readmission shortly after hospital discharge is frequent, identifying inpatients at higher risk is difficult. We evaluated whether in-hospital depressive symptoms (hereafter "depression") are associated with short-term readmission or mortality after discharge from medical wards. METHODS: Depression was assessed at discharge in a prospective inpatient cohort from 2 Canadian hospitals (7 medical wards) and defined as scores ≥ 11 on the 27-point Patient Health Questionnaire (PHQ-9). Primary outcome was all-cause readmission or mortality 90 days postdischarge. RESULTS: Of 495 medical patients [median age 64 years, 51% women, top 3 admitting diagnoses heart failure (10%), pneumonia (10%) and chronic obstructive pulmonary disease (8%)], 127 (26%) screened positive for depression at discharge. Compared with nondepressed patients, those with depression were more frequently readmitted or died: 27/127 (21%) vs. 58/368 (16%) within 30 days and 46 (36%) vs. 91 (25%) within 90 days [adjusted odds ratio (aOR) 2.00, 95% confidence interval 1.25-3.17, P=.004, adjusted for age, sex and readmission/death prediction scores]. History of depression did not predict 90-day events (aOR 1.05, 95% CI 0.64-1.72, P=.84). Depression persisted in 40% of patients at 30 days and 17% at 90 days. CONCLUSIONS: Depression was common, underrecognized and often persisted postdischarge. Current symptoms of depression, but not history, identified greater risk of short-term events independent of current risk prediction rules.

Patient-Reported Discharge Readiness and 30-Day Risk of Readmission or Death: A Prospective Cohort Study.

BACKGROUND: Early readmissions to hospital after discharge are common, and clinicians cannot accurately predict their occurrence. We examined whether patients who feel unready at the time of discharge have increased readmissions or death within 30 days. METHODS: This was a prospective cohort study of adult patients discharged home from 2 tertiary care hospitals in Edmonton, Alberta, Canada, between October 2013 and November 2014. Patient-reported discharge readiness was measured with an 11-point Likert response scale, with scores <7 indicating subjective unreadiness. The primary outcome was readmission or death within 30 days. Logistic regression models were adjusted for age, sex, and a validated risk prediction score for postdischarge events (LACE index). RESULTS: Of 495 patients (mean age 62 years, 51% female, mean Charlson comorbidity index 2.8), 112 (23%) reported being unready for discharge. Risk factors for being unready at discharge were cognitive impairment (mild vs none), low satisfaction with health care services, depression, lower education, previous hospital admissions (12 months), and persistent symptoms or disability. At 30 days, 85 patients (17%) had been readmitted or died, with no significant difference between patients who felt unready or ready (15% vs 18%, adjusted odds ratio 0.84, 95% confidence interval 0.46-1.54, P = .59). CONCLUSIONS: Although nearly one-quarter of hospitalized medical patients reported being unready at the time of discharge, they did not experience any higher risk of readmission or death in the first 30 days after discharge, compared with patients who felt ready for discharge.

Health literacy and nurses' communication with type 2 diabetes patients in primary care settings.

BACKGROUND: The use of the interactive communication loop has been recommended as an effective method to enhance patient understanding and recall of information. OBJECTIVE: The aim of the study was to examine the application of interactive communication loops, use of jargon, and the impact of health literacy (HL) when nurses provide education and counseling to patients with type 2 diabetes in the primary care setting in Alberta, Canada. METHODS: Encounters between nurses and patients with type 2 diabetes were audio recorded, and a patient survey including a HL measure was administered. Topics within each interaction were coded based on five key components of the communication loop and categories of jargon. RESULTS: Nine nurses participated in this study, and encounters with 36 patients were recorded. A complete communication loop was noted in only 11% of the encounters. Clarifying health information was the most commonly applied component (58% often used), followed by repeating health information (33% often used). Checking for understanding was the least applied (81% never used), followed by asking for understanding (42% never used). Medical jargon and mismatched language were often used in 17% and 25% of the encounters, respectively. Patients' HL did not materially affect patterns of communication in terms of using communication loops; however, nurses used less jargon and mismatched words with patients with inadequate HL. DISCUSSION: The overuse of medical jargon accompanied with underuse of communication loop components jeopardizes patients' comprehension and retention of information that they need to know to properly self-manage their diabetes. Nurses need to develop more effective ways to communicate concepts critical to chronic diabetes self-care education and management.