Abstract
BackgroundThe impact of surgery on end of life care for patients with disseminated malignancy (DMa) is incompletely characterized. The purpose of this study was to evaluate postoperative outcomes impacting quality of care among DMa patients, specifically prolonged length of hospital stay, readmission, and disposition.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for years 2011–2012. DMa patients were matched to non-DMa patients with comparable clinical characteristics and operation types. Primary hepatic operations were excluded, leaving a final cohort of 17,972 DMa patients. The primary outcomes were analyzed using multivariate Cox regression models.ResultsDMa patients represented 2.1% of all ACS-NSQIP procedures during the study period. The most frequent operations were bowel resections (25.3%). Compared to non-DMa matched controls, DMa patients had higher rates of postoperative overall morbidity (24.4% vs. 18.7%, p<0.001), serious morbidity (14.9% vs. 12.0%, p<0.001), mortality (7.6% vs. 2.5%, p<0.001), prolonged length of stay (32.2% vs. 19.8%, p<0.001), readmission (15.7% vs. 9.6%, p<0.001), and discharges to facilities (16.2% vs. 12.9%, p<0.001). Subgroup analyses of patients by procedure type showed similar results. Importantly, DMa patients who did not experience any postoperative complication experienced significantly higher rates of prolonged length of stay (23.0% vs. 11.8%, p<0.001), readmissions (10.0% vs. 5.2%, p<0.001), discharges to a facility (13.2% vs. 9.5%, p<0.001), and 30-day mortality (4.7% vs. 0.8%, p<0.001) compared to matched non-DMa patients.ConclusionSurgical interventions among DMa patients are associated with poorer postoperative outcomes including greater postoperative complications, prolonged length of hospital stay, readmissions, disposition to facilities, and death compared to non-DMa patients. These data reinforce the importance of clarifying goals of care for DMa patients, especially when acute changes in health status potentially requiring surgery occur.
Highlights
Surgical interventions among disseminated malignancy (DMa) patients are associated with poorer postoperative outcomes including greater postoperative complications, prolonged length of hospital stay, readmissions, disposition to facilities, and death compared to non-DMa patients
These data reinforce the importance of clarifying goals of care for DMa patients, especially when acute changes in health status potentially requiring surgery occur
The purpose of the present study was to evaluate these outcomes, prolonged length of hospital stay, readmissions, and disposition to facilities other than home, among DMa patients undergoing surgery since these outcomes can clearly impact the quality of life and overall trajectory of disease in patients with incurable malignancy
Summary
Patients and clinicians consider oncologic outcome and survival the pre-eminent goals of cancer therapy, quality of life and avoidance of therapeutic morbidity, among patients with stage IV cancer, are receiving increasing attention as important goals of care.[1,2,3,4,5] Prolonged length of hospital stay, intensive care unit stays, emergency room visits, hospital readmissions, and aggressive therapies, such as chemotherapy and surgery, have come under scrutiny given the increasing emphasis on improved palliative care and quality of life for patients near their end of life.[1,2,3,4,5] These issues create a dilemma for many surgeons, as patients with stage IV cancer commonly present with acute surgical conditions, such as bowel obstructions.[6, 7] In addition, surgeons are frequently faced with questions of whether surgical interventions should be performed electively on this patient population, since symptom palliation and prolongation of life are often potential benefits of surgery.[8, 9] we and others have shown that surgical intervention in this population is associated with high 30-day morbidity and mortality, with rates ranging from 27–44% and 9–11% respectively.[8,9,10,11] It is unclear to what extent this elevated post-surgical morbidity impacts other metrics of surgical outcomes among patients with disseminated malignancy (DMa) such as prolonged postoperative length of hospital stay, hospital readmission following the index surgical procedure, and disposition to facilities such as nursing homes. The impact of surgery on end of life care for patients with disseminated malignancy (DMa) is incompletely characterized. The purpose of this study was to evaluate postoperative outcomes impacting quality of care among DMa patients, prolonged length of hospital stay, readmission, and disposition
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