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Research

Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study

Angela Jerath, Jason Sutherland, Peter C. Austin, Dennis T. Ko, Harindra C. Wijeysundera, Stephen Fremes, Paul Karanicolas, Daniel McCormack and Duminda N. Wijeysundera
CMAJ November 16, 2020 192 (46) E1440-E1452; DOI: https://doi.org/10.1503/cmaj.200068
Angela Jerath
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Jason Sutherland
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Peter C. Austin
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Dennis T. Ko
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Harindra C. Wijeysundera
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Stephen Fremes
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Paul Karanicolas
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Daniel McCormack
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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Duminda N. Wijeysundera
Sunnybrook Research Institute (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas), Division of Cardiology (Ko, H. Wijeysundera), Division of Cardiac Surgery (Fremes) and Department of General Surgery (Karanicolas), Sunnybrook Health Sciences Centre; Department of Anesthesia and Pain Medicine (Jerath, D. Wijeysundera), University of Toronto; ICES Central (Jerath, Austin, Ko, H. Wijeysundera, Fremes, Karanicolas, McCormack, D. Wijeysundera), Toronto, Ont.; School of Population and Public Health (Sutherland), University of British Columbia, Vancouver, BC; Li Ka Shing Knowledge Institute (D. Wijeysundera), St. Michael’s Hospital, Toronto, Ont.
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  • Authors response to letter by Heckman et al. re: Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study.
    Angela Jerath [MSc FRCPC FANZCA MD BSc] and Duminda N. Wijeysundera [PhD FRCPC MD]
    Posted on: 10 January 2021
  • RE: Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study.
    George A Heckman [MD MSc], Stella Arthur [RN MPH] and Andrew P Costa [PhD]
    Posted on: 28 November 2020
  • Posted on: (10 January 2021)
    Authors response to letter by Heckman et al. re: Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study.
    • Angela Jerath [MSc FRCPC FANZCA MD BSc], Clinician (anesthesiologist) scientist, Sunnybrook Research Institute at Sunnybrook Health Sciences Centre
    • Other Contributors:
      • Duminda N. Wijeysundera, Clinician (anesthesiologist) scientist

    Dr. Heckman et al. raise the importance of frailty and delirium as possible contributing factors for delays in hospital discharge and need for continuing care. We support the inclusion of frailty measures in hospital-level national databases to standardize this assessment. Dr. Heckman alludes to a lack of standardized national hospital-level acute care data on frailty. While instruments have been developed to study frailty using administrative data, the tools measure frailty indirectly as a function of age, comorbidity, and pre-hospital residence.1 Hence, some elements within existing frailty indices are captured in our methods although we accept that addition of a frailty index could provide further information on the risk of delayed discharge.2 Hospital databases do not include standardized frailty measures such as the Clinical Frailty Scale or Fried Frailty Index, and are inaccurate sources for studying postoperative delirium.3

    Alternate level of care is an endemic issue within public healthcare systems that impacts patient flow in acute hospitals and wait times. Closer inspection of the scale of alternate level of care for Canadian surgical patients who may have personal care needs and specific post-surgical rehabilitation needs (i.e., physiotherapy after joint replacement) has not been performed. This paper provided the first high-level assessment of alternate level of care use in complex surgical patients.4 Like any early evaluation, we focused on global epi...

    Show More

    Dr. Heckman et al. raise the importance of frailty and delirium as possible contributing factors for delays in hospital discharge and need for continuing care. We support the inclusion of frailty measures in hospital-level national databases to standardize this assessment. Dr. Heckman alludes to a lack of standardized national hospital-level acute care data on frailty. While instruments have been developed to study frailty using administrative data, the tools measure frailty indirectly as a function of age, comorbidity, and pre-hospital residence.1 Hence, some elements within existing frailty indices are captured in our methods although we accept that addition of a frailty index could provide further information on the risk of delayed discharge.2 Hospital databases do not include standardized frailty measures such as the Clinical Frailty Scale or Fried Frailty Index, and are inaccurate sources for studying postoperative delirium.3

    Alternate level of care is an endemic issue within public healthcare systems that impacts patient flow in acute hospitals and wait times. Closer inspection of the scale of alternate level of care for Canadian surgical patients who may have personal care needs and specific post-surgical rehabilitation needs (i.e., physiotherapy after joint replacement) has not been performed. This paper provided the first high-level assessment of alternate level of care use in complex surgical patients.4 Like any early evaluation, we focused on global epidemiological features such as incidence, trends and predictors rather than targeted areas like frailty. Given our paper showed that older adults are at greater risk of alternate level of care, next steps in this line of research includes evaluating why they are at higher risk - with frailty being an important potential explanation.

    We respectfully disagree that all interventions to mitigate risks for delayed hospital discharge should occur before surgery. Upstream rigorously assessed interventions are important, but are by no means the only solution. Timely discharge planning and access to community care are invaluable for safe discharge. Indeed, our paper showed wide variation in alternate level of care status between surgeries. Cardiac surgery likely provides some key lessons for programmatic discharge planning because this patient subgroup is typically older with high levels of frailty yet showed low rates of alternate level of care. Another promising avenue is use of bundled care packages, which are available to Ontario patients having elective hip and knee replacement. Bundled programs link acute hospital to post-acute care, and have lowered hospital lengths of stay and alternate level of care.5

    There is no single magic bullet for resolving alternate level of care. A sequential perioperative team-based approach, where healthcare providers pass on care carefully to the next provider, is needed to optimize recovery at the right times along the patients’ surgical journey.

    Show Less
    Competing Interests: None declared.

    References

    • 1. McIsaac DI, Wong CA, Huang A, Moloo H, van Walraven C. Derivation and Validation of a Generalizable Preoperative Frailty Index Using Population-based Health Administrative Data. Ann. Surg. 2019;270:102-8.
    • 2. Hui Y, van Walraven C, McIsaac DI. How Do Common Comorbidities Modify the Association of Frailty With Survival After Elective Noncardiac Surgery? A Population-Based Cohort Study. Anesth. Analg. 2019;129:1699-706.
    • 3. Katznelson R, Djaiani G, Tait G, et al. Hospital administrative database underestimates delirium rate after cardiac surgery. Can. J. Anaesth. 2010;57:898-902
    • 4. Jerath A, Sutherland J, Austin PC, et al. Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study. CMAJ 2020;192:E1440-E1452.
    • 5. Walker K, Hall RE, Wodchis WP. Hip and Knee Bundled Care Evaluation – Report #2 Trends in Characteristics of Patients Receiving Hip and Knee Replacements. Toronto, ON: Health System Performance Network. 2020
  • Posted on: (28 November 2020)
    RE: Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study.
    • George A Heckman [MD MSc], Schlegel Research Chair in Geriatric Medicine, Schlegel Research Institute for Aging, and University of Waterloo
    • Other Contributors:
      • Stella Arthur, PhD Candidate
      • Andrew P Costa, Assistant Professor and Schlegel Chair in Clinical Epidemiology and Aging

    We commend the authors of the article “Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study” for their robust methodology, but were disappointed that they did not address the concepts of frailty, iatrogenic delirium, and functional decline (1).

    The lack of adequate data on the concepts of frailty and geriatric syndromes in our acute care national data repositories highlights the existence of major gaps in Canada’s health information infrastructure. First, the lack of meaningful data on frailty, delirium and functional decline, reduces these key concepts to “nonmedical reasons” for delayed discharge. Clearly, they are not. Frailty, irrespective of how it is operationalized, has repeatedly been shown to be a more robust predictor of major adverse postoperative outcomes than chronological age (2). Delirium and functional decline are often iatrogenic and thus preventable, including in surgical patients, and delayed discharge can be avoided (3,4). Second, the lack of meaningful data on frailty, and delirium and functional decline leads to the interpretation that “downstream” interventions and resources are required to improve the “flow of patients”, though senior-friendly practices to prevent iatrogenic complications in the first place would be far more efficient. The principles of management rest on systematic screening and assessment of at-risk patients, followed by multidisciplinary non-pharmacological interventions (3,...

    Show More

    We commend the authors of the article “Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study” for their robust methodology, but were disappointed that they did not address the concepts of frailty, iatrogenic delirium, and functional decline (1).

    The lack of adequate data on the concepts of frailty and geriatric syndromes in our acute care national data repositories highlights the existence of major gaps in Canada’s health information infrastructure. First, the lack of meaningful data on frailty, delirium and functional decline, reduces these key concepts to “nonmedical reasons” for delayed discharge. Clearly, they are not. Frailty, irrespective of how it is operationalized, has repeatedly been shown to be a more robust predictor of major adverse postoperative outcomes than chronological age (2). Delirium and functional decline are often iatrogenic and thus preventable, including in surgical patients, and delayed discharge can be avoided (3,4). Second, the lack of meaningful data on frailty, and delirium and functional decline leads to the interpretation that “downstream” interventions and resources are required to improve the “flow of patients”, though senior-friendly practices to prevent iatrogenic complications in the first place would be far more efficient. The principles of management rest on systematic screening and assessment of at-risk patients, followed by multidisciplinary non-pharmacological interventions (3,4).

    It is possible to include concepts of frailty, delirium, and functional decline in our acute care national data repositories. Standardized information on these syndromes is available in the databases for home care and long-term care curated by the Canadian Institute of Health Information, which have been shown to be highly useful at characterizing hospital patients awaiting institutionalization (5). It is high time for standardized information systems compatible with those in home care and long-term care to be implemented in Canadian acute care hospitals.

    Show Less
    Competing Interests: None declared.

    References

    • Angela Jerath, Jason Sutherland, Peter C. Austin, et al. Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study. CMAJ 2020;192:E1440-E1452.
    • Cunha AIL, Veronese N, de Melo Borges S, Ricci NA. Frailty as a predictor of adverse outcomes in hospitalized older adults: A systematic review and meta-analysis. Ageing Res Rev 2019;56:100960. doi: 10.1016/j.arr.2019.100960.
    • Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA 2017 Sep 26;318(12):1161-1174. doi: 10.1001/jama.2017.12067.
    • Patel JN, Klein DS, Sreekumar S, Liporace FA, Yoon RS. Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review. J Am Acad Orthop Surg. 2020 Feb 1;28(3):128-133. doi: 10.5435/JAAOS-D-18-00425.
    • Costa AP, Hirdes JP. Clinical Characteristics and Service Needs of Alternate-Level-of-Care Patients Waiting for Long-Term Care in Ontario Hospitals. Healthc Policy. 2010 Aug;6(1):32-46.
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Canadian Medical Association Journal: 192 (46)
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Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study
Angela Jerath, Jason Sutherland, Peter C. Austin, Dennis T. Ko, Harindra C. Wijeysundera, Stephen Fremes, Paul Karanicolas, Daniel McCormack, Duminda N. Wijeysundera
CMAJ Nov 2020, 192 (46) E1440-E1452; DOI: 10.1503/cmaj.200068

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Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study
Angela Jerath, Jason Sutherland, Peter C. Austin, Dennis T. Ko, Harindra C. Wijeysundera, Stephen Fremes, Paul Karanicolas, Daniel McCormack, Duminda N. Wijeysundera
CMAJ Nov 2020, 192 (46) E1440-E1452; DOI: 10.1503/cmaj.200068
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