Postacute Care After Major Abdominal Surgery in Elderly Patients: Intersection of Age, Functional Status, and Postoperative Complications

Abstract

Importance: Advanced age is an important risk factor for discharge to postacute care (PAC) facilities including skilled nursing and rehabilitation. Factors modifying the age-related risk of discharge to PAC have not been adequately examined for surgical patients.

Objective: To evaluate how preoperative functional status and postoperative complications affect age-related risk of discharge to PAC facilities following major abdominal surgery.

Design, setting, and participants: Retrospective cohort study of 55 238 patients aged 18 years or older having colorectal, pancreas, or liver operations in 2011 and 2012 at hospitals participating in the National Surgical Quality Improvement Program. Age was classified as younger than 65 years, 65 to 74 years, 75 to 84 years, and 85 years or older. The study was conducted between July 1, 2014, and July 1, 2015.

Main outcomes and measures: The primary outcome was discharge to a PAC facility following surgery. The secondary outcome was type of PAC facility (skilled nursing, rehabilitation, or other facility).

Results: Among 55 238 patients (mean [SD] age, 61 [15] years; 49% male) having colorectal, pancreas, or liver operations, 5325 (10%) were discharged to PAC facilities after major abdominal surgery. Skilled nursing facilities were the most common type of PAC (63%), followed by rehabilitation hospitals (30%) and other facilities (7%). Older age was an important predictor of discharge to PAC facilities, but there were significant interaction effects with age and postoperative complications. Among functionally independent patients who avoided postoperative complications, rates of discharge to PAC increased from 1% in the group younger than 65 years to 30% in the group aged 85 years or older. For functionally independent patients with multiple complications, 13% of patients younger than 65 years were discharged to PAC facilities compared with 66% of those aged 85 years or older. After risk adjustment, the oldest patients were 27 times more likely to be discharged to PAC than the youngest group when there were no postoperative complications (odds ratio = 26.6; 95% CI, 21.6-32.7) and 11 times more likely after multiple complications (odds ratio = 11.4; 95% CI, 8.3-15.6). Among functionally dependent patients, the overall risk of discharge to PAC facilities was increased, but age was not as important a predictor for discharge to PAC.

Conclusions and relevance: Older patients are frequently discharged to PAC facilities even when they are functionally independent and without postoperative complications. Helping older patients to return home after surgery and avoid placement in PAC facilities will require innovative programs that go beyond reducing complication rates and enhance postoperative recovery.