Long-Term Fate of Patients Discharged to Extended Care Facilities After Cardiovascular Surgery

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1 Long-Term Fate of Patients Discharged to Extended Care Facilities After Cardiovascular Surgery James R. Edgerton, MD, Morley A. Herbert, PhD, Cecile Mahoney, BS, Drew Armstrong, MS, Todd M. Dewey, MD, Elizabeth Holper, MD, Karen Roper, PhD, and Michael J. Mack, MD Cardiopulmonary Research Science and Technology Institute, and Medical City Dallas Hospital, Dallas, Texas Background. The Society of Thoracic Surgeons predictive algorithms can be used to help patients understand the risks in having a surgical procedure. However, elderly patients are frequently more concerned about the quality of their remaining life and whether they will return home. Currently, we have no predictors of which patients are likely to return to independent living after surgery. We followed patients discharged home or to an extended care facility to determine which patients were most likely to return home and be alive at one year. Methods. This single-hospital, retrospective study followed 590 cardiac surgery patients (January 2008 to December 2009) for at least 1 year after discharge. Followup data were collected by contacting facilities, patients, and families, and Social Security Death Index searches. Results. At hospital discharge, 84.4% went home, 3.7% to rehab, 7.5% to skilled nursing facilities (SNF), and 4.4% to a long-term acute care facility (LTAC). Predictors for facility discharge include increasing age, female, dialysis, emergent status, procedures other than CAB, preoperative stroke, and moderate to severe tricuspid insufficiency. The most significant predictors of dying or still being in a facility at 1 year include being on dialysis, right heart failure, and having chronic lung disease. Considering perioperative complications, requiring prolonged ventilation decreases the odds of being home and alive at 1 year by 67%: one-year survival at home, 95.4%; rehabilitation, 63.6%; SNF, 52.3%; and LTAC, 30.8%. Conclusions. Many patients discharged to extended care do not return to their previous lifestyle; only 30.8% of those requiring care in a LTAC facility are alive at home at 1 year. (Ann Thorac Surg 2013;96:871 8) Ó 2013 by The Society of Thoracic Surgeons Patients are able to make better decisions about their health care when truly informed about all possible outcomes of a proposed procedure. The Society of Thoracic Surgeons (STS) National Database risk algorithms provide information about 30-day mortality and morbidity [1]. However, because this and other risk scoring systems are based on preoperative risk factors, they do not account for the effect of perioperative complications on recovery in the elderly patient. Patients who are discharged to an extended care facility usually have their care transferred to other providers and are not sent back to the surgeon s office for follow-up. It is assumed that these patients eventually are successfully discharged to home, but little data exist to support this assumption. Lacking knowledge of their long-term outcome makes it exceedingly difficult to counsel preoperative patients. According to one estimate [2], approximately 30% of patients with myocardial infarctions, 25% with heart failure, 11% with coronary artery bypass surgeries, and 20% with valve surgeries are discharged to skilled nursing facilities (SNF). Moreover, use of these facilities Accepted for publication April 15, Address correspondence to Dr Edgerton, 4716 Alliance Blvd, Ste 310, Pavilion II, Plano, TX 75093; jimmyedgertonmd@gmail.com. is likely to increase, given the declining lengths of hospital stay in the last few decades [3], with the greatest decline for people aged 65 years and older. It should not be surprising that the number of long-term acute care facilities (LTAC) in the United States has increased at a rate of 8.8% per year [4]. A recent study [5] presented an algorithm identifying preoperative factors and demographic characteristics that are associated with non-home discharge. Our study collected data on discharge location, time of stay in facilities, and mortality at 1 year for patients having cardiac surgery. This study analyzed both preoperative factors and postoperative complications that correlate with discharge outcomes and whether patients were living and at home at 1 year. To obtain consistency in discharge patterns, the hospital has developed printed guidelines outlining the appropriate patient status for transfer to the different facilities from the acute care hospital as well as the care and services provided. [Guidelines: Rehab is for the medically stable patient, focused on regaining pre-illness level of function; SNF is for patients requiring licensed skilled nursing or rehab staff care, daily evaluation, and care for PICC (peripherally inserted central catheter) lines, wound care, speech therapy, intravenous medications; LTAC is for the hemodynamically stable patient with needs too extensive for SNF such as on a ventilator, Ó 2013 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 872 EDGERTON ET AL Ann Thorac Surg PATIENTS DISCHARGED TO EXTENDED CARE FACILITIES 2013;96:871 8 chest tube, needing renal dialysis, or continuous cardiac monitoring.] Material and Methods Using our STS database, we extracted data on all patients undergoing cardiac surgery at Medical City Dallas Hospital between January 2008 and December Patients undergoing heart transplant, ventricular assist device insertion, or a transcatheter valve procedure were excluded; 1 patient s data was not available, leaving 590 patients. The project was approved with waiver of consent status by the North Texas Institutional Review Board, Medical City Dallas. All data were analyzed using SAS 9.3 (SAS Institute, Cary, NC). Patient discharge status was divided into 4 categories; Home, Rehab, SNF, and LTAC. Follow-up after discharge from Medical City was obtained by personal contact of the facilities listed as their discharge destination. When the facility was unable to provide the information, or had closed, we contacted the patient or their family for information. Social Security Death Index searches were carried out on all patients. Statistical Analysis Analyses of categoric variables used c 2 tests; continuous variables were analyzed with t tests for 2-way comparisons or analysis of variance for 4-way comparisons. Odds ratios were calculated using hierarchical model logistic regression. The primary outcome variable was defined as the composite of being alive at 1 year and living at home; patients discharged to a facility had to have been discharged from the facility. To calculate home and alive rates at 1 year, patient follow-up was right censored at 1 year after discharge. Patients have been followed for longer but varying lengths of time. Results Follow-Up The mean follow-up for patients discharged to Home, Rehab, SNF, and LTAC was , , , and days, respectively. Discharge to Home Versus Facility Patients who were discharged to a facility compared with home were older, more likely to be female, have renal failure, and severe chronic lung disease with both the STS predicted risk of mortality and predicted risk of mortality or major morbidity approximately double those discharged home (Table 1). Patients discharged to a facility had statistically higher rates of almost all measured complications, although a few failed to reach statistical significance (Table 2). Reoperation for bleeding was higher in the group discharged to home. Using multivariable nested logistic models, we identified preoperative factors predictive of being discharged to a facility compared with discharge to home. Significant variables were the following: (1) dialysis; (2) moderate to severe tricuspid insufficiency; (3) surgical procedure other than isolated coronary artery bypass grafting (CABG); (4) increasing age; (5) female sex; and (6) emergent operation (Table 3). Patients with prior cardiovascular surgery were significantly less likely to be discharged to a facility than home postoperatively. Table 3 lists significant multivariate predictors of an increased likelihood of having died or still being in a facility at 1 year (versus alive and living at home). Factors included dialysis, moderate to severe tricuspid insufficiency, procedure other than isolated CABG, increasing age, and moderate to severe chronic lung disease. When patients suffer complications, either during or after surgery, it may change the probability of being alive and living at home at 1 year. Using multivariate logistic analysis, we examined the effect of postoperative complications on the outcome of being home and alive at 1 year. The major morbidities defined by the STS were tested (permanent stroke, deep sternal wound infection, new onset renal failure, any reoperation, and prolonged ventilation). Postoperatively, 75.4% (445 of 590) patients had none of these complications while 18.0% (106 of 590) had 1 complication, and the remaining 6.6% (39 of 590) had 2 or more. A parameter for number of events was added to the model with the following increases in the odds ratios for still being in a facility or dead at 1 year. With 1 or more major postoperative morbidity, the odds ratio (compared with 0) was 3.45 (95% confidence interval [CI]: 2.29 to 5.21; p < 0.001), with 2 or more (compared with 0 or 1), was 5.09 (95% CI: 2.45 to 10.59; p < 0.001), and with 3 or more major morbidities (compared with 2 or fewer) was (95% CI: 3.14 to 34.12; p < 0.001). Discharge to a Nursing Facility (SNF or LTAC) Versus Home Patients requiring a high level of nursing care are discharged to either LTAC or SNF depending on specific needs. In most cases, rehabilitation (rehab) facilities accept only medically stable patients who require physical or occupational therapy to return to pre-illness levels. We looked at predictors for patients going to either SNF or LTAC compared with home using both preoperative and perioperative variables (Table 4). Other parameters such as myocardial infarction, previous cardiovascular surgery, New York Heart Association score, or presence of cardiac arrhythmia were not statistically significant. Discharge to Home Versus Rehab, SNF, or LTAC We looked at demographics of patients sent to each type of facility and to home (Table 1). The most frequent operations in our population were CABG (45.8%), isolated valve (25.9%), CABG plus valve (13.2%), and other (15.1%). In the group of patients having a CABG procedure, 92.7% were discharge home while numbers for valve, CAB þ valve, and others were 75.8%, 71.8%, and 84.3%. In the approximately 25% of patients having a valve procedure who are discharged to a facility, onehalf of these go to a SNF.

3 Table 1. Patient Demographics by Discharge Location Variable Home Rehab SNF LTAC p Value a All Facilities p Value b Number of patients Age, years < <0.001 STS predicted < <0.001 risk-mortality (%) STS predicted < <0.001 risk-mortality or major morbidity (%) Preop hematocrit < <0.001 Males 70.3% (350/498) 72.7% (16/22) 43.2% (19/44) 46.2% (12/26) < % (47/92) <0.001 Arrhythmia 18.9% (94/498) 27.3% (6/22) 31.8% (14/44) 50.0% (13/26) < % (33/92) <0.001 Smoker 20.5% (102/498) 18.2% (4/22) 6.8% (3/44) 7.7% (2/26) % (9/92) Preop renal failure 6.2% (31/498) 4.5% (1/22) 15.9% (7/44) 23.1% (6/26) % (14/92) On dialysis 2.0% (10/498) 4.5% (1/22) 4.5% (2/44) 15.4% (4/26) < % (7/92) Preop creatinine level Diabetes 33.3% (166/498) 31.8% (7/22) 43.2% (19/44) 46.2% (12/26) % (38/92) Insulin-dependent diabetes 45.8% (76/166) 42.9% (3/7) 42.1% (8/19) 66.7% (8/12) % (19/38) Preoperative stroke 7.0% (35/498) 9.1% (2/22) 13.6% (6/44) 11.5% (3/26) % (11/92) NYHA - class III/IV 6.0% (30/498) 4.5% (1/22) 9.1% (4/44) 19.2% (5/26) % (10/92) Severe chronic lung disease 3.4% (17/498) 0 2.3% (1/44) 11.5% (3/26) % (4/92) Left main disease > 50% 21.7% (108/497) 9.1% (2/22) 22.7% (10/44) 7.7% (2/26) % (14/92) Three-vessel disease 53.7% (267/497) 54.5% (12/22) 56.8% (25/44) 34.6% (9/26) % (46/92) BMI (kg/m 2 ) Hypertensive 76.5% (381/498) 90.9% (20/22) 86.4% (38/44) 69.2% (18/26) % (76/92) Preop myocardial infarction 30.1% (150/498) 27.3% (6/22) 31.8% (14/44) 19.2% (5/26) % (25/92) First cardiovascular surgery 79.5% (396/498) 86.4% (19/22) 84.1% (37/44) 69.2% (18/26) % (74/92) Previous CABG surgery 17.5% (87/498) 13.6% (3/22) 15.9% (7/44) 19.2% (5/26) % (15/92) Previous PCI procedure 34.3% (171/498) 9.1% (2/22) 31.8% (14/44) 19.2% (5/26) % (21/92) Ejection fraction a p value compares distribution of home, rehab, SNF, and LTAC. b p value compares home to facility as a group. BMI ¼ body mass index; CABG ¼ coronary artery bypass grafting; LTAC ¼ long-term acute care; NYHA ¼ New York Heart Association; PCI ¼ percutaneous coronary intervention; Preop ¼ preoperative; Postop ¼ postoperative; Rehab ¼ rehabilitation; SNF ¼ skilled nursing facility STS ¼ Society of Thoracic Surgeons. Ann Thorac Surg EDGERTON ET AL 2013;96:871 8 PATIENTS DISCHARGED TO EXTENDED CARE FACILITIES 873

4 Table 2. Postoperative Complications by Discharge Location Variable Home Rehab SNF LTAC p Value a Facilities All Number of patients Length of stay hospital (days) < <0.001 Any complication 45.9% (228/497) 77.3% (17/22) 68.2% (30/44) 96.2% (25/26) < % (72/92) <0.001 Prolonged ventilation (>24 hours) 11.5% (57/497) 18.2% (4/22) 27.3% (12/44) 84.6% (22/26) < % (38/92) <0.001 Septic 0.2% (1/497) 4.5% (1/22) 2.3% (1/44) 15.4% (4/26) < % (6/92) <0.001 Permanent stroke 1.0% (5/497) 22.7% (5/22) 0 3.8% (1/26) < % (6/92) <0.001 Reop- cardiac reason 2.0% (10/497) 4.5% (1/22) 11.4% (5/44) 19.2% (5/26) < % (11/92) <0.001 Reop- noncardiac reason 1.6% (8/497) 22.7% (5/22) 4.5% (2/44) 50.0% (13/26) < % (20/92) <0.001 Postop heart block 1.8% (9/497) 4.5% (1/22) 6.8% (3/44) 15.4% (4/26) < % (8/92) <0.001 Pleural effusion 9.9% (30/302) 14.3% (1/7) 31.8% (7/22) 77.8% (7/9) < % (15/38) <0.001 Postop renal failure 6.6% (33/497) 18.2% (4/22) 11.4% (5/44) 30.8% (8/26) < % (17/92) <0.001 Renal failure requiring dialysis 2.0% (10/497) 0 4.5% (2/44) 19.2% (5/26) < % (7/92) Total ICU hours < <0.001 Total ventilator usage (hours) < <0.001 Postop creatinine level < Cross-clamp time (minutes) < Perfusion time (minutes) < Total units of blood product used < <0.001 Postop GI comps 1.0% (5/497) 4.5% (1/22) 0 7.7% (2/26) % (3/92) Readmitted to ICU 4.6% (23/498) 4.5% (1/22) 11.4% (5/44) 15.4% (4/26) % (10/92) Reop- bleeding 2.6% (13/497) % (1/26) % (1/92) Postop Afib 25.8% (128/497) 27.3% (6/22) 31.8% (14/44) 30.8% (8/26) % (28/92) Alive at 1 year 95.4% (475/498) 77.3% (17/22) 75.0% (33/44) 42.3% (11/26) < % (61/92) <0.001 Home and alive at 1 year 95.4% (475/498) 63.6% (914/22) 52.3% (23/44) 30.8% (8/26) < % (45/932) <0.001 a p value compares distribution of home, Rehab, SNF and LTAC. b p value compares home to facility as a group. Afib ¼ atrial fibrillation; GI ¼ gastrointestinal; ICU ¼ intensive care unit; LTAC ¼ long-term acute care; Postop ¼ postoperative; Rehab ¼ rehabilitation; Reop ¼ reoperative; SNF ¼ skilled nursing facility. p Value b 874 EDGERTON ET AL Ann Thorac Surg PATIENTS DISCHARGED TO EXTENDED CARE FACILITIES 2013;96:871 8

5 Ann Thorac Surg EDGERTON ET AL 2013;96:871 8 PATIENTS DISCHARGED TO EXTENDED CARE FACILITIES Table 3. Multivariate Predictors of Discharge to Facility Versus Home, and for Being at Home and Alive at 1 Year Versus Still in Facility Discharge to Facility vs Home 875 Still in Facility or Dead vs Home-Alive at 1 Year Parameter Comparison OR (95% CI) p Value OR (95% CI) p Value Age Per year increase 1.07 ( ) < ( ) <0.001 Dialysis Requires dialysis vs none ( ) < ( ) <0.001 Tricuspid Insufficiency (Moderate-severe) vs 3.26 ( ) ( ) <0.001 (None-trivial-mild) Operative category Other than iso CABG 2.92 ( ) < ( ) Chronic lung disease Moderate-severe vs none-mild NS 2.10 ( ) Sex Female vs male 1.70 ( ) NS Status Emergent vs others 5.63 ( ) NS Previous CV surgery Yes vs no 0.58 ( ) NS Stroke (preoperative) Yes vs no 2.10 ( ) NS CI ¼ confidence interval; CV ¼ cardiovascular; iso CABG ¼ isolated coronary artery bypass grafting; NS ¼ not significant; OR ¼ odds ratio. Table 2 lists postoperative complications of patients. Any postoperative complication resulted in a greater likelihood of discharge to a location other than home. In patients discharged to LTAC, 96.2% had at least 1 complication. Complications in patients discharged to a facility included prolonged ventilation, atrial fibrillation, pleural effusion, renal failure, and reoperation. Further, they had increased operating room time, intensive care unit time, length of stay, and increased blood product utilization. Figure 1 shows the proportion of patients from each discharge location that died, went home or to other facility type. The final row is the number of patients who were home and alive at 1 year. For patients discharged to a facility initially, the mean number of days spent in that facility until discharge is an average of (median 22) days, (median 21) days, and (median 30) days in rehab, SNF, and LTAC, respectively. The calculation of facility days only counts time in the first facility. The status at 1 year was based only on events occurring before or at the 1 year mark; subsequent deaths are not included in the calculation. The percentage of patients alive at 1 year (either at home or still in a facility) was significantly different based on initial discharge location; home (95.4%), rehab (77.3%), SNF (75.0%), and LTAC (42.3%), p less than The percentage of patients who were both at home and alive at 1 year based on discharge location was home (95.4%), rehab (63.6%), SNF (52.3%), and LTAC (30.8%), p less than The Kaplan-Meier curves (Fig 2) show surviving fractions of patients stratified by discharge location. The presented data include all available follow-up. Comment Cardiac surgery patients seek relief of symptoms with an expectation of a return to a high quality life, usually implying independent living. The STS database data only tracks patients for 30 days. In patients who require discharge to an extended care facility, 30-day mortality data are not representative of the patient s outcome at 1 year. Patients discharged to an extended care facility frequently do not return to their previous lifestyle. They have a high (31.5%) 1-year mortality, low likelihood (55%) of returning to independent living, and at 1 year Table 4. Odds Ratios for Discharge to a Nursing Facility (SNF, LTAC) Compared With Home Parameter Change OR(95% CI) p Value Age 1-year increase 1.07 ( ) <0.001 Sex Female vs male 2.51 ( ) <0.001 Operative category Other than iso CABG 2.02 ( ) <0.001 Surgical status Emergent vs elective/urgent 4.29 ( ) Tricuspid insufficiency Moderate-severe vs none/trivial/mild 3.76 ( ) Stroke Yes vs no 2.29 ( ) Postop complications 3 or more vs ( ) < or more vs ( ) < or more vs ( ) <0.001 CI ¼ confidence interval; iso CABG¼ isolatedcoronary arterybypassgrafting; LTAC¼ long-termacute carefacility; OR ¼ odds ratio; Postop ¼ postoperative; SNF ¼ skilled nursing facility.

6 876 EDGERTON ET AL Ann Thorac Surg PATIENTS DISCHARGED TO EXTENDED CARE FACILITIES 2013;96:871 8 Fig 1. Final distribution of patients from each discharge location. (LTAC ¼ long-term acute care; Rehab ¼ rehabilitation; SNF ¼ skilled nursing facility.) postoperatively, only 50% are alive and in their own home. The fate is worst for those who require LTAC with only 30.8% being alive and at home at 1 year. This study looked at the long-term outcome of patients discharged to extended care facilities after cardiac surgery and the likelihood that patient will successfully transition back to living at home. Although the results are sobering, being able to provide this information to patients (especially the elder) contributes to truly informed consent. For this study, we used alive and at home at 1 year as the measure of regaining an acceptable quality of life. Many patients are willing to undergo a stay at an extended care facility if they know they will eventually make it home. However, if they expect to spend the rest of their lives in a facility, some would prefer to forgo an operation and live out the natural history of their disease in their own home. Our study has determined predictors that will help a patient know his likelihood of attaining independent living after cardiac surgery. If patients become incapacitated from postoperative complications, families may be called upon to make decisions regarding whether to pursue aggressive care or to start withdrawing life sustaining therapies. To make these decisions they require more than just the chance of survival; they need the likelihood of the patient attaining a meaningful quality of life. Henry and colleagues [6] also looked at predictors of discharge to an extended care facility and, similar to our study, found that age, female gender, concomitant valve/ CABG were significant factors. They also found chronic lung disease, and STS risk score predicted non-home discharge. Postoperative complications that correlated with non-home discharge included any complication, renal failure, and prolonged ventilation. Pattakos and colleagues [5] studied this same problem from a different focus. Their concern was that patients going to extended care facilities have prolonged hospital stays while such arrangements are being made; identification of these patients would allow early planning and reducing length of stay, thus the need to determine predictors. As opposed to the Pattakos and colleagues study, which was aimed at reducing length of stay, our focus was to help patients and families make informed decisions at 2 Fig 2. Kaplan-Meier survival curves for patients discharged to home and different facilities. (LTAC ¼ long-term acute care; REHAB ¼ rehabilitation; SNF ¼ skilled nursing facility.)

7 Ann Thorac Surg EDGERTON ET AL 2013;96:871 8 PATIENTS DISCHARGED TO EXTENDED CARE FACILITIES levels. The first is the decision to proceed with cardiac surgery. The predictors for not being alive and in your own home 1 year after surgery include increasing age, dialysis dependency, and moderate to severe tricuspid insufficiency. We expect that tricuspid insufficiency is a marker for structural heart disease in these patients. The failing left or right ventricle frequently results in measurable tricuspid insufficiency, which often improves after repair of the left side [7, 8]. A second decision point may occur for families of patients who have suffered 1 or more complications. Frequently, these patients are in the intensive care unit, sedated, on a ventilator and the family needs to decide whether to proceed aggressively or not. This decision frequently depends on the expected quality of life if the patient survives. If the predicted quality is good, the family is likely to proceed aggressively; if poor, they may wish to withhold aggressive measures. Once a patient has sustained a number of complications, predictors that they will not be alive and at home 1 year later include new renal insufficiency, tricuspid insufficiency, prolonged ventilation, and increasing age. This knowledge may help guide a family to make decisions, including identifying patients who would benefit from palliative care consultation. Early involvement of a palliative care team has been shown to reduce length of stay [9]. A study of our tables reveals that patients discharged to LTAC fared worst, while those discharged to a rehabilitation facility did best. This is not surprising; to be accepted to a rehab facility requires that the patient be able to tolerate 3 hours each day of rehab activities while patients discharged to LTAC are frequently nonambulatory and may be on a ventilator. There may be important implications for health care resource utilization. For most patients cardiac surgical care is working well, with over 95% of patients discharged home still alive at 1 year. However, our data show that in some patients, cardiac surgical care resulted in less than the anticipated and desired result. These patients who ended being discharged to extended care were also the ones who utilized the greatest amount of resources (ventilator hours, days in ICU, blood product usage, and total length of stay). One third of these patients were dead a year later, and among the group sent to LTAC, 57.7% were dead a year later. Further, only 50% of these patients achieved the desired result of alive and in their home 1 year later, and among those discharged to LTAC this number fell to 30.8%. A disproportional amount of resources are being expended on these patients without achieving the desired result. Spending on long-term care services just for the elderly is projected to increase at least two-and-a-half times and could nearly quadruple in constant dollars to $379 billion by the year 2050 [10]. Currently, fully 50% of health care dollars are spent in the last year of life [11]. These statistics are alarming and add further emphasis to better understand the risks and benefits (value) of long-term care, and the costs and value of such care. Health care financing is facing reforms and seeking new paradigms; no one is interested in expending resources that result in a lifestyle unsatisfactory to the patient. In conclusion, we find that patients discharged to an extended care facility after cardiac surgery frequently do not return to their previous lifestyle. The fate is worst for those who require a LTAC. Knowledge of factors which predict a patient having a poor outcome at 1 year is important when counseling patients and families. This study is limited by being small, single centered, and retrospective. Other factors that may contribute to a patient s successful outcome (eg, frailty, resilience, social support, and spirituality) and their nutritional status were not available for analysis. References Dewey TM, Brown DL, Das TS, et al. High-risk patients referred for transcatheter aortic valve implantation: management and outcomes. Ann Thorac Surg 2008;86: Dolansky MA, Zullo MD, Hassanein S, Schaefer JT, Murray P, Boxer R. Cardiac rehabilitation in skilled nursing facilities: a missed opportunity. Heart Lung 2012;41: Centers for Disease Control and Prevention. Table 103 Discharges, days of care, and average length of stay in nonfederal short-stay hospitals, by selected characteristics: United States, selected years 1980 through In: Sebelius K, Frieden TR, Sondik EJ, eds. Health, United States, 2011 With Special Feature on Socioeconomic Status and Health. 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