What Happens to Patients Who Can't Go Home? Missing Morbidity and Determinants of Outcomes for Surgical and Trauma Patients Discharged to Skilled Nursing Facilities.
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Background The surgical population is aging, and with this comes associated increases in comorbid conditions among our surgical patients. This demographic change has accompanied increased awareness of the risks associated with prolonged hospitalization, as well as ballooning medical expenditures. These forces together have steadily increased pressure to decrease hospital stay and have driven a shift in post-operative rehabilitation from the acute care hospital to post-acute care facilities. Many surgeons think of PAC as a transitional phase prior to returning home, but the increased mortality during this period challenges this assertion. While greater burden of disease contributes to the increased mortality among SNF patients, the potential role of the care setting to outcome and survival has not been properly studied. This area of care currently represents a "black box" to most practicing surgeons, but represents a large area of "missing morbidity" in surgical outcomes. Methods We performed a 5-state, 3-year retrospective cohort analysis of Medicare beneficiaries discharged to skilled nursing homes following acute care hospitalizations for surgical, trauma, and non-trauma stroke diagnoses. three primary analyses were performed in this study: 1) an analysis of first discharge disposition following SNF admission for PAC; 2) an analysis of post-discharge survival following SNF admission in relationship to diagnosis group and first discharge disposition from SNF, including setting of death; and 3) a comparison of long-term survival in relationship to clinical and patient characteristics ascertained upon admission to SNF. Data from these analyses were then used to develop an interactive tool to predict probability of discharge home, readmission, and 1-year mortality, which was developed in 3 states and validated in the remaining 2 states. Results Among 323,128 patients discharged to skilled nursing facilities, 3.8% died during the index SNF admission, 28.6% were readmitted to an acute care hospital, 60.5% were discharged back to home, 5.6% transitioned to assisted-living facilities, and 1.6% were still in a SNF at 6 months following admission. Almost 50% of readmissions occurred within 7 days. Readmission was the strongest predictor of long-term mortality. Cumulative 1 and 3-year mortality was 26.1% and 31.3% respectively. Factors associated with mortality were male gender, increasing comorbidities, decreasing functional status, impaired cognitive status, ICU stay, pressure ulcers, and the requirement for parental nutrition. The risk prediction tools developed showed good predictive value, with a c-statistic of 0.74 for trauma patients, 0.77 for surgical patients, and 0.69 for non-trauma stroke patients. Conclusion It is often communicated to patients and families that discharge to a SNF is just another step in the process of recovery with a high expectation of a return to home. However, a growing body of literature and the current study suggest that this is an overly simplistic description of the process. A significant proportion (41%) never discharge back to home and the 1 and 3-year risk of death is much greater than population norms. It remains to be determined to what degree care delivery at the SNF contributes to these outcomes or the extent of outcome variability between SNFs.
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