Ann Thorac Surg 2007;83:483-489
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Discharge to Home Rates Are Significantly Lower for Octogenarians Undergoing Coronary Artery Bypass Graft Surgery
Hasmet Bardakci, MDa,
Faisal H. Cheema, MDa,*,
Veli K. Topkara, MDa,
Nicholas C. Dang, MDa,
Timothy P. Martens, MDa,
Michelle L. Mercandoa,
Catherine S. Forstera,
Ariel A. Bensonb,
Isaac George, MDa,
Mark J. Russo, MDa,
Mehmet C. Oz, MDa,
Barry C. Esrig, MDa,b
a Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University–New York Presbyterian Hospital, New York, New York
b Division of Cardiothoracic Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
Accepted for publication September 14, 2006.
* Address correspondence to Dr Cheema, College of Physicians and Surgeons of Columbia University–New York Presbyterian Hospital, 177 Fort Washington Ave, Milstein Hospital Bldg 7GN-435, New York, NY 10032 (Email: fc2020{at}columbia.edu).
Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
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Abstract
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BACKGROUND: The incidence of coronary artery bypass graft surgery (CABG) performed in elderly patients has been increasing over recent years. We sought to evaluate clinical outcomes of octogenarians undergoing CABG using an audited state-wide mandatory database.
METHODS: New York State Department of Health’s Cardiac Reporting System was analyzed from 1998 to 2002. In all, 88,154 patients undergoing isolated CABG were identified. Patients were divided into four age groups: less than 50 years (group 1, n = 6,527), 50 to 64 years (group 2, n = 30,088), 65 to 79 years (group 3, n = 43,369), and 80 years and above (group 4, n = 8,170).
RESULTS: Of all patients, 9.3% were octogenarians. In addition to marginally worse coronary artery disease, octogenarians generally manifested a higher incidence of preoperative risk factors such as cerebrovascular disease, peripheral vascular disease, and congestive heart failure compared with younger patients at baseline. Both length of hospital stay and in-hospital mortality rate were significantly higher among octogenarians. The incidence of postoperative complications was higher among octogenarians. Multivariate analysis demonstrated renal failure requiring dialysis (odds ratio [OR] = 4.4), myocardial infarction within 6 hours before surgery (OR = 3.6), chronic obstructive pulmonary disease (OR = 1.7), congestive heart failure at admission (OR = 1.7), emergent operation (OR = 1.6), Canadian Cardiovascular Society functional class IV (OR = 1.5), hypertension (OR = 1.4), and low ejection fraction (OR = 0.98) to be significant independent predictors of in-hospital mortality of octogenarians. Discharge to home rates were significantly lower for octogenarians.
CONCLUSIONS: Although early outcomes in octogenarians are acceptable, these factors alone are not sufficient to reflect overall success of CABG in these patients, given the strikingly lower discharge to home rates. Attention to full functional recovery in octogenarians is essential.
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Introduction
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The number of people over the age of 80 in the United States in 1990 was 6.9 million, and is anticipated to increase to more than 25 million by the year 2050 [1]. In a similar manner, the incidence of cardiac operations among elderly patients has also been increasing [2]. The elderly are expected to have a higher rate of morbid outcomes after surgery than younger people, despite recent advancements in technology, pharmacotherapy, and perioperative management that are improving postoperative outcomes. Coronary artery disease is increasingly prevalent in the elderly population. With advances in surgical technique, the incidence of coronary artery bypass graft surgery (CABG) performed in elderly patients has been increasing over recent years. However, owing to the rapid expansion of this procedure within an older population, outcomes have yet to be determined through a large cohort of patients. Using a large mandatory database, we describe the current outcomes of patients 80 years old or greater undergoing CABG with a focus on morbidity, short-term mortality, and discharge status.
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Patients and Methods
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Patient Population
The New York State Department of Health maintains and audits a mandatory registry for all adult patients who undergo cardiac surgery in the state. The data were obtained from this registry for the years 1998 to 2002. The data used for these analyses are collected from 37 participating hospitals as part of the New York State Department of Health’s Cardiac Surgery Reporting System, which is overseen and audited by the New York State Department of Health’s Bureau of Hospital and Primary Care Services, Cardiac Services Program. The Institutional Review Board of Columbia University approved the use of these data for this study and waived the need for patient consent. Only those patients who underwent isolated coronary artery bypass grafting as the sole procedure were included in this study. Patients who had a combined CABG and valvular or congenital heart procedures were excluded from this analysis. In all, 88,154 CABG surgery patients were identified, divided into four age groups: less than 50 years (n = 6,527, 7.4%; group 1), 50 to 64 years (n = 30,088, 34.1%; group 2), 65 to 79 years (n = 43,369, 49.2%; group 3), and 80 years or older (n = 8,170, 9.3%; group 4), and their clinical outcomes were determined.
Demographics and Risk Factors
Demographic and preoperative variables included age, sex, race, body mass index, Canadian Cardiovascular Society (CCS) angina classification, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, renal failure, hepatic failure, previous myocardial infarction, smoking history, carotid, aortoiliac, and femoropopliteal arterial disease, preoperative intra-aortic balloon pump use, preoperative ejection fraction, coronary vessel disease distribution, congestive heart failure, percutaneous transluminal coronary angioplasty, and previous heart operation history (Appendix). The operative details included priority of surgery (elective, urgent, emergent), off-pump approach, and minimally invasive surgery. Postoperative complications included number of major adverse events, stroke, myocardial infarction, sepsis or endocarditis, reoperation for bleeding, gastrointestinal bleeding, renal failure, respiratory failure. End outcomes included total hospital length of stay, in-hospital mortality, and discharge status. Discharge placement locations included home, acute care facilities, skilled nursing home, hospice, and other facilities.
Statistical Analysis
Data were represented as frequency distributions and percentages. Values of continuous variables were expressed as means ± SD. Continuous variables were compared using independent samples t tests, whereas categorical variables were compared by means of 
2 tests. Univariate analysis was carried out for the 80 years or older age group. For multivariate analysis, only variables with a p value less than 0.25 by univariate analysis were entered into a logistic regression analysis model [3]. This model is a multiple regression analysis for examining dichotomous outcomes such as early mortality versus no early mortality and their potential associated risk factors by modeling a linearized function of a set of covariates. The interpretation of a risk factor allowed into the final model with a p value less than 0.05 is that it is an independent risk factor associated with the event, over and above other potential risk factors included in the equation. All statistical analyses were performed using SPSS 11.5 software (SPSS, Chicago, Illinois).
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Results
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Baseline Characteristics
The preoperative clinical characteristics of patients within the age groups are summarized in Table 1. In comparison with the younger age group, a greater number of octogenarians were women. While the number of patients undergoing CABG increased according to age groups among whites, the opposite trend was seen among blacks and other races. More octogenarians were CCS class IV and had a higher history of hypertension, congestive heart failure and remote myocardial infarction before surgery. Peripheral arterial diseases were higher in octogenarians than in younger patients. Octogenarians had a lower mean body mass index and lower history of smoking, preoperatrive intra-aortic balloon pump use, and percutaneous transluminal coronary angioplasty. They also had a lower mean preoperative ejection fraction than the younger group. Whereas octogenarians had a significantly higher incidence of renal failure, they were less likely to be on dialysis. Frequencies of major coronary artery disease were higher among octogenarians than among younger patients (Table 2).
Operative Details
In general, octogenarians had a higher frequency of urgent and emergent operations than the younger groups. Compared with younger patients, a greater number of octogenarians underwent off-pump CABG (Table 3).
Postoperative Complications
The incidences of postoperative stroke (both within and beyond 24 hours), bleeding requiring reoperation, sepsis or endocarditis, gastrointestinal bleeding perforation or infarction, renal failure requiring dialysis, and respiratory failure were all significantly higher among octogenarians than the other younger groups (Table 4).
End Outcomes
The length of hospital stay (Fig 1) and in-hospital mortality (Fig 2) were both significantly higher for patients 80 years old or older than for younger patients (both p < 0.001). The discharge to home rates were significantly lower in octogenarians than in younger patients. There were significantly more discharges to acute care facilities, skilled nursing homes, and other facilities for octogenarians compared with the younger group (Fig 3).
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Fig 1. Length of stay. *p  0.001. (Solid bar = fewer than 50 years; checkered bar = 50 to 64 years; open bar = 65 to 79 years; cross-hatched bar = 80 years or more.)
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Fig 2. In-hospital mortality. *p 0.001. (Solid bar = fewer than 50 years; checkered bar = 50 to 64 years; open bar = 65 to 79 years; cross-hatched bar = 80 years or more.)
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Fig 3. Discharge locations. *p 0.001. (Solid bars = fewer than 50 years; checkered bars = 50 to 64 years; open bars = 65 to 79 years; cross-hatched bars = 80 years or more.)
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Multivariate Analysis of Octogenarian Subgroup
Multivariate logistic regression analysis was performed in the subset of patient population of 80 years old and above. Significant independent predictors of in-hospital mortality of octogenarians were identified as renal failure on dialysis, acute myocardial infarction within 6 hours before surgery, chronic obstructive pulmonary disease, congestive heart failure at admission, emergent operation, CCS class IV, hypertension, and low ejection fraction (Table 5).
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Table 5. Independent Predictors of In-Hospital Mortality in Octogenarians: Results From a Multivariate Logistic Regression Model
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Comment
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Our study confirms that octogenarians had significantly higher rates of major adverse events, such as stroke, reoperation for bleeding, sepsis, gastrointestinal bleeding, and renal and respiratory failure than younger patients, in addition to the longer hospital length of stay and higher in-hospital mortality [4–10]. However, the outcomes seem improved over time when compared with previous reports [11–15]. On the other hand, these hard endpoints alone are not sufficient to reflect the clinical outcomes in these patients. Postoperative patient disposition and discharge status should also be considered as an important component of overall CABG success, as these have important implications regarding functional status and quality of life. Recent studies report a high incidence of death or discharge to nursing care facilities among octogenarians who survive cardiac surgery [11, 15, 16].
We found that the discharge to home rates was significantly lower for octogenarians as compared with younger patients. There were significantly more discharges to acute care facilities, skilled nursing homes, and other facilities among octogenarians than among younger age groups. The presence of comorbid conditions in octogenarians might predict their discharge to facilities other than home. Also, considering the higher frequency of urgent and emergent operations in octogenarians, we suspect a trend of delayed referral for CABG. Further detailed reports investigating referral times to operation are warranted.
The functional recovery to baseline for octogenarians undergoing CABG remains understudied. Several authors have suggested that patients who are discharged to skilled nursing facilities benefit from fewer functional activities and, hence, have increased morbidity and mortality [11, 17–20]. In a recent study comparing 104 patients over the age of 80 years with younger patients who underwent cardiac surgery, Avery and colleagues [15] reported that 47% of octogenarians were discharged to skilled nursing care facilities. The total direct cost was 27% higher in the elderly cohort than in the younger cohort, with the largest increases noted in critical care, medical-surgical nursing, and respiratory cost centers [15]. Another study conducted by Rady and Johnson [11] evaluated the clinical outcomes and disposition of 783 patients, 96 of which were octogenarians. They reported that 39% of octogenarian patients, as opposed to 13% of younger patients, had such poor functional recovery after cardiac surgery that transfer to a nursing care facility was necessary. They concluded that these facts should be taken into consideration during evaluation of operative outcomes in this population [11]. What we have shown in our study is that 11.5% of patients were discharged to skilled nursing homes and another 27.7% to acute care facilities, leaving behind a total of 52.4% who were actually discharged to home.
Although our study represents a multicenter experience involving a large number of patients and included discharge status in addition to morbidity and mortality, it still has several limitations. Despite the auditing process, the New York State Department of Health’s Cardiac Advisory Committee that maintains this database believes that the short-term complications may be undercoded. As endpoints within the database are simply defined as death or discharge disposition, data are lacking beyond these occurrences. There is no information related to hospital readmission, late death, or return to home. Moreover, from a qualitative standpoint, while discharge to home is generally regarded to be a more favorable disposition than, say, discharge to a skilled nursing facility, formal quality of life assessment is lacking in this study. Knowledge of surgically related events that occur within the discharge facilities would prove to be valuable. Indeed, the morbidity and mortality of the patients discharged to acute care facilities, skilled nursing homes, hospices, and other facilities would grant us more accurate follow-up information regarding survival and quality of life after CABG for octogenarians. Future studies comparing quality of life before and after cardiac surgery should be designed to address this issue. Another limitation of this study lies in that we did not have data on the location of patients at the time of referral for CABG. Therefore, it is difficult to conclude how many patients were truly discharged to these facilities for the first time.
Lastly, the financial costs of acute care facilities are not insignificant and would need to be taken into consideration when assessing the true socioeconomic impact of surgical therapy and discharge disposition in these particular patients. Unfortunately, such cost information is missing from this study. Previous reports acknowledge that controversy exists as to whether the considerable proportion of healthcare resources expended on elderly patients actually represents a cost-effective approach, especially when postoperative quality of life issues are taken into consideration [21]. On the other hand, Sollano and colleagues [22] have shown that surgery for octogenarians is cost effective and the quality of life of patients who underwent surgery is greater than that of their medically managed cohorts with multivessel coronary artery disease, and equates it to that of an average 55-year-old person in the general population.
The presence of comorbid conditions in octogenarians predicts their discharge to facilities other than home. To decrease mortality and morbidity and increase the discharge-to-home rate in this population, any comorbid condition should be carefully managed and treated before surgery. The lower mean body mass index in octogenarians compared with younger patients may be a contributing factor to the difficult healing and delayed recovery in this group, which in turn contributes to a higher incidence of comorbid conditions and postoperative complications [23]. Therefore, nutritional status of patients, including serum albumin levels, should be evaluated before surgery. If deemed necessary, dietary supplementation consisting of a balanced regimen of protein, fats, carbohydrates, micronutrients, and antioxidants might be initiated to nutritionally optimize patients preoperatively. The encouragement of active postoperative rehabilitation programs may also contribute to enhanced outcomes.
In summary, multivariate analysis shows that in the presence of some comorbid conditions, the mortality may be increased manifold. The logistic regression model identified dialysis-dependent renal failure, myocardial infarction within 6 hours before the surgery, chronic obstructive pulmonary disease, congestive heart failure at admission, emergent operation, Canadian cardiac scale angina class IV, hypertension and low preoperative ejection fraction as independent predictors of in-hospital mortality among octogenarians. Furthermore, the discharge to home for these patients is significantly low. Hence, patients with any comorbid conditions should be dealt with carefully.
We conclude that with the results of current surgical practice, the outcomes after coronary artery bypass grafting among octogenarians seem acceptable in reference to morbidity and in-hospital death rates. However, these variables alone are not adequate to reflect the overall success of coronary bypass operation on patients aged 80 years or older. In addition to refining of surgical techniques, better understanding and management of the frequently associated comorbidites in this population is mandatory to improve the overall results. During the interpretation of these results, the discharge status of these patients should be considered one of the key components in the process of outcome assessment. The significantly lower discharge to home rates demonstrates that the early outcomes alone are not sufficient enough to accurately portray the actual results within this population. Attention to full functional recovery in octogenarians is essential. Long term quality of life data in octogenarian patients should also be gathered, and the results should be incorporated into the surgical decision-making process.
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Appendix
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Risk Factors
Preoperative Chronic Medical Morbidity Risk Factors
- 1 Myocardial infarction (MI): either clinical or electrocardiographic evidence was required for a diagnosis of previous MI. For patients having previously diagnosed MI, the duration since the most recent MI was noted. Transmural MI was diagnosed by the presence of new Q waves and a rise in creatine kinase heart muscle-specific isoenzyme to a level indicating MI.
- 2 Hypertension: a diagnosis of hypertension was made if a blood pressure more than 140/90 mm Hg was documented, there was a history of hypertension, or the patient was currently taking antihypertensive medication.
- 3 Congestive heart failure during admission for CABG: congestive heart failure at New York Heart Association level III or IV occurring during this admission.
- 4 Congestive heart failure before this admission: if the patient has been treated for congestive heart failure before this admission, but is not in congestive heart failure at level III or IV during this admission.
- 5 Stroke: a history of stroke, with or without residual defect.
- 6 Carotid/cerebrovascular disease: patients who have more than 50% cerebral artery obstruction, have a history of a nonembolic stroke, or have required an operation for such disease. A history of bruits or transient ischemic attacks was not sufficient evidence for carotid/cerebrovascular disease.
- 7 Peripheral vascular disease: (1) patients who have significant vascular disease in the aorta or iliac arteries, or who have been previously operated for such disease; (2) patients who have had prior revascularization of femoropopliteal vessels, have absent or diminished pulses, or in whom an attempt to insert a balloon-assist device fails because of diminished femoral arteries, or in whom an angiogram demonstrates a greater than 50% narrowing in a major femoral or popliteal vessel.
- 8 Chronic obstructive pulmonary disease: patients who are functionally disabled, or require bronchodilator therapy, or have a forced expiratory volume in 1 second (FEV1) less than 75% or less than 1.25 L, or have a pO2 less than 60 mm Hg and a pCO2 greater than 60 mm Hg on room air.
- 9 Diabetes mellitus: patients with diabetes mellitus requiring either oral hypoglycemic agents or insulin.
- 10 Renal failure: patients with a preoperative creatinine greater than 2.5% or patients with renal failure on chronic peritoneal or hemodialysis.
- 11 Hepatic failure: patients with an established diagnosis of cirrhosis and with a bilirubin level greater than 2 mg/dL and a serum albumin less than 3.5 g/dL.
Perioperative Risk Factors
- 1 Preoperative intra-aortic balloon pump: if the patient arrives in the operating room with an intra-aortic balloon pump or requires its insertion before the induction of anesthesia.
- 2 Previous percutaneous transluminal coronary angioplasty: if the patient had a percutaneous transluminal coronary angioplasty either during or before this admission.
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Acknowledgments
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We are indebted to New York State’s Cardiac Advisory Committee and the other staff of the New York State’s Department of Health for their support in this study; and to the cardiac surgery departments and their staff members of the 37 participating hospitals for their tireless efforts to ensure the timeliness and accuracy of the registry data. We would further like to thank Jennifer Quill, Dr Catherine Wang, Candice Bailon, and Joanne Michelle Washburn for their administrative help throughout the completion of this project.
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Abstract
Introduction
