Abstract
Purpose
To evaluate the association between frailty and post-operative discharge destination after different types of commonly performed urologic procedures in older patients.
Materials and Methods
Using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2011–2013, we identified commonly performed inpatient urologic procedures among patients age 65 and older. We then assessed the effect of frailty, measured by the NSQIP Frailty Index (NSQIP-FI), on discharge to a skilled or assisted living facility using logistic regression and assessed the heterogeneity of this effect across procedures using two-level random effects modeling.
Results
Overall, 1,144 out of 20,794 (5.5%) urologic cases, representing 19 different procedures, resulted in discharge to a skilled or assisted living facility. Cystectomy and large TURBT had the highest percentage at 16.3%. 25% of patients undergoing urology procedures were frail (NSQIP-frailty index [FI] 0.18+), including 9.8% of patients discharged to a facility. Even after adjustment for year, age, race, type of anesthesia, smoking status, recent weight loss, and whether or not the procedure was elective, frailty was strongly associated with discharge to a facility [adjusted OR 3.1 (96% CI 2.5, 3.8) for NSQIP-FI 0.18+ compared to NSQIP FI 0]. This finding was consistent across most procedures of varying complexity with an overall effect of OR 1.6 (95% CI 1.5, 2.0).
Conclusions
Increasing frailty is associated with discharge to a skilled or assisted living facility across most inpatient urologic procedures evaluated, regardless of complexity. This information is important for preoperative counseling with patients undergoing urologic surgery.
Introduction
More than two-thirds of all urologic procedures are performed in individuals ages 65 years and older.1 Some of these individuals experience acute functional decline after surgery and are unable to return home immediately post-operatively.2 While 10–40% of older individuals undergoing various non-urologic surgeries are discharged to skilled or assisted living facilities,3–8 similar data on urologic surgery are limited to complex procedures such as cystectomy, and information on more commonly performed urologic procedures is lacking.
Frailty, expressed as a physiologic decrease in capacity resulting from stressors, has been identified as a risk factor for non-home discharge among patients undergoing non-urologic surgery.3,9,10 The effect of frailty on patients undergoing urologic surgery, however, has been limited to 30-day morbidity and mortality,11–14 and its effects on discharge destination have not been well characterized. This is problematic because discharge to a facility can be life changing for an individual, is strongly associated with increased 12 month mortality,3 and is very costly to society.15
Using data from the American College of Surgeons National Quality Improvement Program (ACS NSQIP), we examined baseline frailty and its association with discharge to skilled or assisted living facilities among patients undergoing various types of inpatient urologic surgery of varying complexity in the United States from 2011 to 2013.
Materials and Methods
Patients and Databases
We used data from the ACS NSQIP Participant Data Use File from 2011 to 2013 to conduct a retrospective cross-sectional study. This study was determined to be exempt by our institution’s Institutional Review Board. The NSQIP database uses clinical reviewers employed by each hospital and specifically trained by the ACS to examine patient records and extract post-operative clinical data and outcomes up to 30 days, including discharge destination.16
We identified urologic cases by the surgical subspecialty variable for all procedures except for sling operations for stress incontinence, which also included procedures performed by gynecologists. We then narrowed our focus to the 20 most commonly performed urologic procedures in the inpatient setting during our study period in the NSQIP database. Two of the codes identified were for cystectomy and were therefore combined for analyses, leaving 19 separate procedures in total. Of note, the code for laparoscopic prostatectomy includes robotic prostatectomy.
Outcomes
Our primary outcome of interest was discharge destination. Patients discharged to skilled care facilities (e.g., transitional care units, subacute hospitals, ventilator beds, and skilled nursing homes), assisted living and other care facilities that are not skilled nursing homes and were not the patient’s home preoperatively, and rehab facilities were categorized as “discharged to a skilled or assisted living facility”. We excluded patients who died, came from a facility preoperatively, or whose discharge status was unknown. All other patients were categorized as being discharged to home.
Covariates
We used the NSQIP Frailty Index (NSQIP-FI) in order to calculate frailty in our cohort. The NSQIP-FI was adapted from the Canadian Heath and Aging-Frailty Index (CSHA-FI) for use specifically with NSQIP data and includes items such as functional status and impaired sensorium that can easily be solicited from patient history. This index has been demonstrated to have greater precision in measuring frailty than the Charlson Comorbidity Index, and has been shown to distinctly measure frailty, as opposed to comorbidity, in all surgical subspecialties including urology. NSQIP-FI scores are summed and divided by the total number of items (11). Patients with 2 or more frailty items on the NSQIP-FI with a score of 0.18 (2/11) or greater were defined as frail for the purposes of this paper, consistent with the literature.17
Additional baseline covariates for demographic and case-based characteristics were abstracted from the NSQIP database. These include the following: calendar year of the procedure, age (by decade), race, type of anesthesia, smoking status, recent weight loss (defined as >10% loss of body weight in the last 6 months), and whether or not the surgery was performed electively. Of note, we purposefully chose variables that would be available to surgeons in the preoperative period so that findings from this study could be applied to the preoperative counseling discussion.
Statistical Analysis
Demographic and case-based characteristics were reported as frequencies and percentages. Items were compared based on discharge destination (home versus skilled or assisted living facility) using chi square tests for significance. In order to evaluate the demographic and case-based characteristics associated with discharge to a skilled or assisted living facility, unadjusted and adjusted logistic regression modeling was performed adjusting for calendar year, age, race, type of anesthesia, smoking status, recent weight loss, whether or not the procedure was elective, and NSQIP-FI.
Because we looked at a heterogeneous mix of urologic procedures, we wanted to determine whether certain procedures were driving our results or if our results were generalizable across procedures. In order to do this we used a two-level random effects model in which the association between frailty and discharge to a skilled or assisted living facility was assessed both within each procedure and then across procedures. Due to low numbers of discharges to skilled or assisted living facilities for hydrocelectomy (0.2%) and radical prostatectomy (0.2%), these procedures were excluded from this part of the analysis. The log odds ratios (and 95% CIs) were combined using a random effects models to provide a summary of the association between frailty and discharge to a skilled or assisted living facility across procedures. Models compared NSQIP-FI >/=0.18 in reference to NSQIP FI=0.
Results
Among the 19 most commonly performed urologic procedures in the NSQIP database from 2011 to 2013 there were 21,938 individuals discharged home and 1,144 (5.5%) individuals discharged to a skilled or assisted nursing facility. Baseline demographic and surgical characteristics are described in Table 1. Overall, 25% of patients undergoing these 19 commonly performed inpatient urologic surgeries were frail and 9.8% of frail patients were discharged to a skilled or assisted living facility. This proportion was higher than other subgroups examined – 5.2% of individuals ages 71–80, 6.4% of African Americans, 5.4% of patients undergoing general anesthesia, and 6.9% of smokers were discharged to skilled or assisted living facilities. Notably, 18.1 % of older individuals with recent weight loss and 17.1% who underwent non-elective surgery were discharged to such facilities.
Table 1.
Characteristics of patients discharged home vs to a skilled or assisted living facility
| Home (n=20,794) | Skilled/assisted living facility (n=1,144) | ||||
|---|---|---|---|---|---|
| freq | % | Freq | % | P value | |
| Year | |||||
| 2011 | 5523 | 95.0 | 291 | 5.0 | 0.10 |
| 2012 | 7262 | 95.1 | 376 | 4.9 | |
| 2013 | 8009 | 94.4 | 477 | 5.6 | |
| Age | |||||
| 65–70 | 9405 | 98.1 | 184 | 1.9 | <0.01 |
| 71–80 | 8234 | 94.8 | 453 | 5.2 | |
| 80+ | 3155 | 86.2 | 507 | 13.8 | |
| Race | |||||
| White | 14133 | 94.0 | 902 | 6.0 | 0.07 |
| African American | 1017 | 93.6 | 69 | 6.4 | |
| Other | 563 | 96.2 | 22 | 3.8 | |
| Anesthesia | |||||
| General | 18064 | 94.6 | 1038 | 5.4 | <0.01 |
| MAC | 143 | 88.3 | 19 | 11.7 | |
| Other | 2576 | 96.7 | 87 | 3.3 | |
| Smoking status | |||||
| Smoker | 2068 | 93.1 | 153 | 6.9 | <0.01 |
| Non-smoker | 18726 | 95.0 | 991 | 5.0 | |
| Recent weight loss | |||||
| No | 20523 | 95.0 | 1084 | 5.0 | <0.01 |
| Yes | 271 | 81.9 | 60 | 18.1 | |
| Elective surgery | |||||
| Yes | 19107 | 96.0 | 806 | 4.0 | <0.01 |
| No | 1612 | 82.9 | 332 | 17.1 | |
| NSQIP Frailty Status | |||||
| 0 | 6075 | 97.6 | 152 | 2.4 | <0.01 |
| .09 | 9712 | 95.6 | 445 | 4.4 | |
| .18+ | 5007 | 90.2 | 547 | 9.8 | |
Frequencies of discharge to a skilled or assisted living facility for specific urologic procedures are listed in Table 2. Of note, the inpatinet urologic procedure with the highest frequency of discharge to a facility was cystectomy and large transurethral resection of bladder tumor (TURBT) (15.5%) followed by nephrectomy with lymph node dissection (both at 16.3%). The procedures with the lowest frequency of discharge to a skilled or assisted living facility were sling surgery for stress urinary incontinence, laparoscopic/robotic prostatectomy, and prostatectomy with lymph node dissection (all <1.0%).
Table 2.
Proportion of patients discharged to a skilled or assisted living by urologic procedure.
| Procedure | Number | % |
|---|---|---|
| Cystectomy with LND | 267/1638 | 16.3 |
| TURBT – large | 78/478 | 16.3 |
| Nephrectomy with LND | 79/625 | 12.6 |
| TURBT – medium | 49/413 | 11.9 |
| Nephrectomy with partial ureterectomy | 53/483 | 11.0 |
| Lap nephrectomy | 64/626 | 10.2 |
| TURBT – small | 32/372 | 8.6 |
| Partial nephrectomy | 59/853 | 6.9 |
| Radical nephrectomy | 83/1284 | 6.5 |
| Laser TURP | 43/693 | 6.2 |
| Lap nephrectomy with partial ureterectomy | 47/814 | 5.8 |
| Prostatectomy – open | * | 4.8 |
| TURP | 166/4194 | 4.0 |
| TURP regrowth | 22/599 | 3.7 |
| Lap partial nephrectomy | 29/1325 | 2.2 |
| Prostatectomy with extended LND | * | 1.6 |
| Sling procedure for stress urinary incontinence | * | 0.8 |
| Lap prostatectomy | 38/5358 | 0.7 |
| Prostatectomy with LND | * | 0.2 |
These procedures had individual cell sizes <20, which are non-reportable by NSQIP standards.
LND=Lymph node dissection
VC=vena cava
Lap=laparoscopic
Unadjusted and adjusted logistic regression models identifying factors associated with discharge to a skilled or assisted living facility are shown in Table 3. Increasing frailty was associated with higher odds of discharge to a skilled or assisted living facility [adjusted OR 1.5 (95% CI 1.2, 1.9) for NSQIP-FI 0.09 and adjusted OR 3.1 (95% CI 2.5, 3.8) for NSQIP-FI 0.18+], when compared to NSQIP-FI 0.
Table 3.
Factors associated with discharge to a skilled or assisted living facility after urologic surgery.
| Events/N (%) | Unadjusted OR | 95% CI | Adjusted OR | 95% CI | |
|---|---|---|---|---|---|
| Year | |||||
| 2011 | 291/5814 (5.0%) | 1.0 | 1.0 | ||
| 2012 | 376/7638 (4.9%) | 1.0 | (0.8, 1.2) | 1.1 | (0.9, 1.3) |
| 2013 | 477/8486 (5.6%) | 1.1 | (1.0, 1.3) | 1.2 | (1.0, 1.5) |
| Age | |||||
| 65–70 | 184/9589 (1.9%) | 1.0 | 1.0 | ||
| 71–80 | 453/8687 (5.2%) | 2.8 | (2.4, 3.3) | 2.9 | (2.4, 3.5) |
| 80+ | 507/3662 (13.8%) | 8.2 | (6.9, 9.8) | 8.7 | (7.2, 10.7) |
| Race | |||||
| White | 902/15035 (6.0%) | 1.0 | 1.0 | ||
| African American | 69/1086 (6.4%) | 1.1 | (0.8, 1.4) | 1.1 | (0.8, 1.4) |
| Other | 22/585 (3.8%) | 0.6 | (0.4, 0.9) | 0.6 | (0.4, 0.9) |
| Anesthesia | |||||
| General | 1038/19102 (5.4%) | 1.0 | 1.0 | ||
| MAC | 19/162 (2.3%) | 2.3 | (1.4, 3.8) | 1.0 | (0.6, 1.9) |
| Other | 87/2663 (3.3%) | 0.6 | (0.5, 0.7) | 0.3 | (0.2, 0.5) |
| Smoking status | |||||
| Non-smoker | 991/19717 (5.0%) | 1.0 | 1.0 | ||
| Smoker | 153/2221 (6.9%) | 1.4 | (1.2, 1.7) | 1.7 | (1.4, 2.1) |
| Recent weight loss | |||||
| No | 1084/21607 (5.0%) | 1.0 | 1.0 | ||
| Yes | 60/331 (18.1%) | 4.2 | (3.1, 5.6) | 2.5 | (1.8, 3.5) |
| Elective surgery | |||||
| No | 332/1944 (17.1%) | 1.0 | 1.0 | ||
| Yes | 806/19913 (4.0%) | 0.2 | (0.2, 0.2) | 0.4 | (0.3, 0.5) |
| NSQIP Frailty Index | |||||
| 0 | 152/6227 (2.4%) | 1.0 | 1.0 | ||
| 0.09 | 445/10157 (4.4%) | 1.8 | (1.5, 2.2) | 1.5 | (1.2, 1.9) |
| 0.18+ | 547/5554 (9.8%) | 4.4 | (3.6, 5.2) | 3.1 | (2.5, 3.8) |
Additional variables associated with discharge to a skilled or assisted living facility include increasing age [adjusted OR 2.9 (95% CI 2.4, 3.5) for ages 71–80 and adjusted OR 8.7 (95% CI 7.2, 10.7) for ages 80+ compared to ages 65–70], smoking status [adjusted OR 1.7 (95% CI 1.4, 2.1)], and recent weight loss [adjusted OR 2.5 (95% CI 1.8, 3.5)]. Races other than white or African American [adjusted OR 0.6 (95% CI 0.4, 0.9)], anesthesia techniques other than general or monitored assisted care (MAC) [adjusted OR 0.3 (95%CI 0.2, 0.5)], and elective surgery [adjusted OR 0.4 (95% CI 0.3, 0.5)] were all associated with a decreased likelihood of being discharged to a skilled or assisted living facility.
We found that frailty was associated with discharge to a skilled or assisted living facility for most inpatient urologic procedures examined with the exception of laser TURP [log odds effect −0.08 (95% CI −0.7, 0.6)]. Nephrectomy with lymph node dissection, TURP regrowth, medium size TURBT, laparoscopic nephrectomy, partial nephrectomy, small TURBT, open prostatectomy all had a similar trend but did not reach statistical significance. The remainder of the procedures evaluated demonstrated a significant association between increased frailty and discharge to a skilled or assisted living facility including the following: cystectomy, large TURBT, laparoscopic nephrectomy with lymph node dissection, laparoscopic/robotic prostatectomy, radical nephrectomy, TURP, nephrectomy with partial ureterectomy and prostatectomy with extended lymph node dissection. The overall log OR of the summary statistic across all procedures was significant at 0.5 (95% CI 0.4, 0.7). Of note, this is a log odds ratio, not an odds ratio, so any number exceeding 0 represents a positive result. A log odds ratio of 0.5 is equivalent to and odds ratio of 1.6.
Discussion
We found that frailty is strongly associated with discharge to skilled or assisted living facilities among patients undergoing most types of inpatient urologic surgery of varying complexity. Additionally, discharge to a skilled or assisted living facility was associated with older age, smoking and recent weight loss, while races other than white and African American, anesthesia techniques other than general, and the surgery being elective were associated with a decreased likelihood of discharge to these facilities. For specific procedures, overall discharge rates to skilled or assisted living facilities ranged from <1% for sling surgery for stress urinary incontinence, laparoscopic/robotic prostatectomy, and prostatectomy with lymph node dissection to 16.3% after cystectomy and large TURBT.
Our finding that increasing frailty was significantly associated with increasing log odds of discharge to a skilled or assisted living facility was consistent across many urologic inpatient procedures ranging from and TURP to laparoscopic prostatectomy to various nephrectomy procedures to cystectomy. For the few procedures in which frailty did not reach statistical significance for this association, they did follow the same trend of a positive association between frailty and discharge to skilled or assisted living facilities. Thus, the importance of considering frailty in the pre-operative setting exists for both “big” and “small” procedures and should be considered in pre-operative discussions among older patients.
Studies examining discharge status for patients undergoing urologic surgery are limited and focuses primarily on oncologic procedures. One study using the Nationwide Inpatient Sample found that 16.3% of patients undergoing cystectomy were discharged to subacute care facilities in the year 2000,18 which is similar to our estimate of 16.3% now 10 years later. In our study, cystectomy was associated with a higher use of non-home discharges than any other urologic procedure except large TURBT. However, this number is lower than other types of non-urologic procedures among older adults, such as colectomy (40%), pancreatectomy (46%), open abdominal aortic aneurysm repair (45%),19 and hip fracture surgery (35%).4 While the reason behind the lower discharge rates to skilled and assisted living facilities among urologic procedures compared to these non-urologic procedures is beyond the scope of this study, some hypotheses may include that urologic patients are healthier, that urologic procedures are well tolerated by older individuals, or that urologists may be underutilizing post operative care in such facilities. Overall, however, the number of patients discharged to such facilities after urologic surgery is relatively low, indicating that these patients tend to do well.
Studies from outside the field of urology have also identified several factors associated with of non-home discharges, including frailty. One study evaluated patients undergoing major elective procedures including general surgery, cardiac surgery, thoracic surgery, urology and vascular surgery, who were admitted to the intensive care unit post-operatively. Up to 30% of these patients required discharge to an institution other than home and factors for this outcome included several variables related to frailty: older age, Charlson >/=3, Hematocrit <35%, any functional dependence, Up-and-Go test >/=15 seconds, albumin <3.4 mg/dL, Mini-Cog>/=3, and having fallen in the last 6 months. Further analysis using multivariate logistic regression found that a prolonged Up-and-Go test and any functional dependence were the strongly associated with discharge to an institutional facility.20 Additional studies in women undergoing surgery for epithelial ovarian cancer found that 12.8% had non-home discharges post-operatively, similar to our rates for many urologic procedures in our study. Advanced age, worse ECOG performance status, greater ASA score and higher CA-125 were all identified as risk factors for non-home discharges.10 Advanced age, poor functional status, and inpatient complications were also strongly associated with non-home discharges among patients undergoing colectomy, pancreatectomy, and open abdominal aortic aneurysm repair.19
This study should be interpreted with certain limitations in mind. First, we are limited by the nature of the NSQIP database in the level of detail that is available for analysis and for the definition of frailty. However, we used the NSQIP-FI, which is a validated instrument designed to measure frailty using these data.17 Another limitation of this study is that it uses data collected from hospitals that volitionally report their outcomes to the ACS. These institutions may differ from those who are not a part of this database and may not be generalizable beyond this group of hospitals. Additionally, there are several other factors that may influence discharge to a skilled or assisted living facility that relate to the hospitalization, such as length of stay and post-operative complications, that were not evaluated in this study. We chose to only evaluate factors that were available pre-operatively since the purpose of this study was to assist in the pre-operative counseling process.
Conclusions
Frailty is common among patients who undergo urologic surgery -- 25% of individuals undergoing common urologic procedures qualified as frail, based on our study criteria. Increasing frailty was associated with discharge to a skilled or assisted living facility among patients undergoing most types of urologic surgery of varying complexity. Overall, however, the number of patients discharged to such facilities after urologic surgery is low, indicating that these patients tend to do well. These data can be used in preoperative counseling of patients undergoing urologic surgery, as knowledge of possible discharge to a non-home facility may influence the decision-making process and should be a part of pre-operative counseling for older patients.
Figure 1.
Acknowledgments
Funding:
Dr. Suskind’s time was supported by the National Institute of Diabetes and Digestive Kidney Diseases (grant number K12 DK83021-07). Dr. Walter’s work on this project was supported by the National Institute on Aging at the National Institutes of Health (grant number K24AG041180). This work was also supported by the UCSF CTSI Scholars Program and the UCSF Claude D. Pepper Older Americans Independence Center.
Footnotes
The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
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