It’s been just over
2 years since Harlan Krumholz described the “Post-hospital
syndrome—an acquired, transient condition of generalized risk” (Krumholz
2013). He described that
recently hospitalized patients experience a period of generalized risk for a
range of adverse health events and called this a post-hospital syndrome, “an
acquired, transient period of vulnerability”. He suggested that the “the risks
in the critical 30-day period after discharge might derive as much from the allostatic and physiological stress that patients
experience in the hospital as they do from the lingering effects of the original
acute illness”. This state
leaves patients vulnerable to readmission, often for conditions different from
that of the index hospitalization.
He went on to
describe some of the likely factors contributing to this reduction of
functional reserve, including metabolic derangements, disturbed sleep patterns,
nutritional factors, cognitive factors, pain and other discomforts, etc.
Obviously, there is
considerable overlap here with the concept of frailty and reduced
physiologic reserves, which we have discussed in many columns (see the full
list at the end of today’s column). In addition, functional impairment and
functional dependence are related to frailty and are part of the same
spectrum. Yet these have generally received much less attention than frailty
(other than in the long-term care literature).
Now a new study has looked at the impact of functional impairment, as measured by
difficulty with instrumental activities of daily living (IADL) or activities of
daily living (ADL), on readmission rates for seniors (Greysen
2015). The researchers found
a progressive increase in the adjusted risk of readmission as the degree of functional
impairment increased.
Activities of daily living (ADL) include bathing, dressing, transferring, toileting, and eating.
Instrumental ADL’s (IADL) require higher levels of functioning and include
things like managing finances, shopping, using the phone, taking medications as
prescribed, preparing meals, and using transportation.
Greysen and colleagues found a progressive increase
in the adjusted risk of readmission as the degree of functional impairment
increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or
more instrumental activities of daily living, 14.4% with difficulty with 1 or
more ADL, 16.5% with dependency in 1 to 2 ADLs, and 18.2% with dependency in 3
or more ADLs.
Subanalysis for those conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia)
revealed the same trend with larger effects (16.9% readmission rate for no
impairment vs 25.7% for dependency in 3 or more ADLs, a 70% increase in risk of
readmission).
Many of our columns
on frailty have focused on outcomes in patients undergoing surgery. While
frailty and functional dependence are two separate entities, they are very much
interrelated and part of the same spectrum. Though frailty risk assessments are
generally simple, they are not routinely captured on hospitalized patients,
whereas functional assessments are often captured (for example, in nursing
assessments). Another set of researchers (Scarborough
2015), therefore, looked at
functional status and its impact on patients in the ACS-NSQIP database who
underwent complex general or vascular operations over a 5-year period. Compared
to a propensity-matched cohort, dependent patients had 1.75-fold greater odds
of postoperative death than functionally independent patients. They also had a
significantly higher incidence of major morbidity (51% higher),
failure-to-rescue, and reoperation compared to functionally independent
patients. The authors strongly recommend that functional status assessment
become a routine part of the preoperative assessment. They note that in some
cases the functional impairment might be able to be modified in the
preoperative period (eg. through physical therapy).
It would also identify a group of patients likely to need additional services
postoperatively and at discharge. And it would provide patients and physicians
a more realistic expectation of outcomes.
In an editorial
accompanying the Scarborough study Robinson and Rosenthal (Robinson
2015), names you’ll recognize from the frailty literature, note that 14 new
geriatric focused variables are being collected by 23 NSQIP medical centers in
a pilot project. The hope is that these will be used to quantify frailty
accurately in older adults and further expand on the already considerable
evidence base on the relationship between frailty and surgical outcomes.
Burke and Jha (Burke
2015), commenting on the Greysen study, note that
hospitals serving a patient population with more functional dependency will
have a more difficult time reducing readmissions. However, they note that
functional dependency and preventing declines in functional dependency are
obviously very important to patients and their families and would actually be
excellent quality metrics for health systems and accountable care
organizations.
We’ve long
considered assessment for frailty to be one of the three most important
components of a good preoperative assessment (the other two being assessments
for delirium risk and obstructive sleep apnea). We also mentioned assessment of
a patient’s ability to perform activities of daily living in our August 17,
2010 Patient Safety Tip of the Week “Preoperative
Consultation – Time to Change”. Given the findings in the current
study by Scarborough and colleagues, doing a formal functional assessment before
patients are admitted for elective surgery would make a lot of sense. And, for
those patients admitted emergently for surgery or admitted to nonsurgical
services, doing the functional assessment obviously provides important
information about potential extra services the patient may need after acute
hospitalization.
We expect we’ll see
a lot more in the future about functional dependence, its measurement, and
interventions to improve it or prevent deterioration.
Some of our prior
columns on frailty:
References:
Krumholz HM. Post-hospital
syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013; 368(2): 100-102
http://www.nejm.org/doi/full/10.1056/NEJMp1212324
Greysen SR, Cenzer
IS, Auerbach AD, Covinsky
KE. Functional Impairment and Hospital Readmission in Medicare Seniors. JAMA Intern Med 2015;
Published online February 02, 2015
http://archinte.jamanetwork.com/article.aspx?articleid=2107610
Scarborough JE, Bennett KM, Englum
BR, et al. The Impact of Functional Dependency on Outcomes after Complex
General and Vasular Surgery. Annals of Surgery 2015;
261(3): 432–437
Robinson TN, Rosenthal RA. Optimizing the Geriatric
Preoperative Assessment: The Use of Functional Dependence and Beyond. Annals of
Surgery 2015; 261(3): 438–439
Burke LG, Jha AK. Patients’
Functional Status and Hospital Readmissions. Remembering What Matters (Invited
Commentary). JAMA
Intern Med 2015; Published online February 02, 2015
http://archinte.jamanetwork.com/article.aspx?articleid=2107607
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