Patient Age Significantly Influences Post-Esophagectomy Inpatient Mortality, Length of Stay, Hospital Charges, and Discharge Disposition

Research Article

Patient Age Significantly Influences Post-Esophagectomy Inpatient Mortality, Length of Stay, Hospital Charges, and Discharge Disposition

Esther H Cha, Gregory Burgoyne and Richard F Heitmiller^*
Department of Surgery, MedStar Union Memorial Hospital, USA

^*Corresponding author: Richard F Heitmiller, Department of Surgery, MedStar Union Memorial Hospital, 3333 N. Calvert Street, JPB Suite 610, Baltimore, Maryland, USA

Published: 06 Jul 2017
Cite this article as: Cha EH, Burgoyne G, Heitmiller RF. Patient Age Significantly Influences Post-Esophagectomy Inpatient Mortality, Length of Stay, Hospital Charges, and Discharge Disposition. Clin Surg. 2017; 2: 1539.

Abstract

Background: There are conflicting reports on the merits of surgery in older esophageal cancer patients. The objective of this study is to track inpatient outcome, hospital charges, and discharge disposition as a function of age.
Study Design: The Nationwide Inpatient Sample was searched for all patients from 2006 to 2010 with a primary diagnosis of esophageal cancer (ICD-9: 150) and underwent esophagectomy (ICD-9: 424). Cervical and upper third malignancies (ICD-9: 150.0 & 150.3) were excluded. Data recorded included age, gender, mortality, length of stay (LOS), hospital charges, discharge, disposition, and diagnosis and procedure codes. Patients were stratified into three age groups: < 55; 55-74; 75 years and older. Results were analyzed using Chi2 and ANOVA.
Results: 9,970 patients were included in this study. 81.2% were male. Mean age, mortality, LOS and charges were 63.3 years, 6.1%, 16.9 days and $161,229 respectively. For the age groups < 55, 55-74, ≥75 respectively, mortality was 2.5, 6.3, 10.3% (p<0.01); LOS was 15.3, 16.8, 19.4 days (p<0.01). There was a significant increase need for post-discharge skilled nursing facility based on age. Home health care was common for all groups (41.2-46.4%).
Conclusion: Post-esophagectomy in-patient mortality, LOS, inpatient charges and the need for post-discharge to skilled nursing facility increase significantly with age. Inpatient charges alone underestimate the overall cost of esophagectomy care. These results should help in selecting esophageal cancer patients for surgery.
Keywords: Esophagectomy; Esophageal cancer; Age; Nationwide inpatient database; Esophagectomy; Cancer; Patient age; Mortality; Charges; Discharge; Disposition; Length of stay; LOS

Abbreviations

ASA: American Society of Anesthesiologist; CGA: Comprehensive Geriatric Assessment; ECOG: Eastern Cooperative Oncology Group; LOS: Length of stay; NIS: National Inpatient Sample; SEER: Surveillance, Epidemiology, and End Results

Introduction

Esophagectomy for patients with esophageal cancer remains a complex surgery, associated with significant morbidity and mortality despite advances in surgical technique and post-operative care. The number of elderly patients with esophageal cancer that present for surgical evaluation is increasing [1]. The purpose of this study is to assess the function of age with respect to outcomes and hospital charges of esophageal cancer patients undergoing surgery. This data will allow improved patient selection as well as provide reasonable expectations regarding outcomes and discharge disposition following surgery.

Methods

A retrospective cohort study was designed to evaluate patients following esophagectomy for esophageal cancer. Data were gathered from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 2006 to 2010 [2]. The study was exempt from formal review by the Institutional Review Board as the NIS data lacks discrete patient identifiers.
ICD-9-CM diagnosis and procedure codes were used to select patients with a primary diagnosis of esophageal cancer (ICD-9-CM diagnosis code 150.X) and who underwent esophageal resection (ICD- 9-CM procedure code 42.4X). Cervical and upper third malignancies (ICD-9-CM diagnosis code 150.0 and 150.3 respectively) were excluded to limit potential confounding variables, such as head and neck malignancies. Data reviewed included the following: total number of patients, mean age, gender distribution, and mortality rate, mean length of stay (LOS), mean hospital charges and discharge disposition. Discharge disposition is characterized by four categories: 1) routine discharge home without any additional assistance; 2) home with home health assistance; 3) transfer to a skilled-nursing facility; 4) transfer to another hospital such as acute rehabilitation.
Patients were stratified to three groups based upon age: Group 1: Age < 55 years-old; Group 2: Age 55 - 74 years old; Group 3: Age ≥75 years-old. Analysis of these three groups was performed to determine mean mortality, mean LOS and percentage distribution across the discharge options. Furthermore, patients were stratified by age (in decades) to determine distribution of disease by age as well as mortality.
Our hypothesis is that outcomes and hospital charges after esophageal resection for the three patient age groups would be significantly different. Continuous and categorical data were evaluated with uni-variate analysis of variance (ANOVA) and chisquared analysis, respectively, using Microsoft Office Excel 2007® (Microsoft, Redmond, WA, USA). Significance was determined with a p-value less than α: 0.05.

Figure 1

Figure 1
Total esophagectomy cases by age.

Figure 2

Figure 2
Mortality rate by age.

Results

A total of 9,971 patients undergoing esophagectomy for cancer of the middle and lower esophagus from 2006 to 2010. Data for mortality rate, age, gender distribution, LOS and hospital charges are summarized by year in (Table 1). For this 5 year period, there were an average of 1,994 cases per year (1,720-2,234) and a total of 613 deaths with a mean mortality rate of 6.1% (4.1% - 8.2%). The mean overall age was 63.3 years (62.7-63.7) and the majority of the patients were male (81.2%) compared to female patients (18.8%). The mean overall LOS was 16.9 days (16.1-17.8) with mean hospital charges of $161,229. Results for the three age groups (< 55 year; 55 - 74 years; ≥75) including mean mortality rate, LOS, discharge disposition and hospital charges are summarized in Table 2. Statistical analysis showed a significant difference in mortality (2.5%; 6.3%; 10.3%), LOS (15.3; 16.8; 19.4) and hospital charges ($146,605; $157,612; $198,639) between the three age groups (p<0.01).
Significant differences (p< 0.01) were also noted between the age groups of patients of who underwent routine discharge (45.2%; 32.8%; 15.8%), were discharged home with home health (46.4%; 45.4%; 41.2%) or were transferred to a skilled nursing facility (5.1%; 14.5%; 31.6%).Transfer to another hospital showed no significant difference (p: 0.74). Figure 1 shows the distribution of esophagectomy cases for esophageal cancer across age by decade with the majority of cases between the ages of 50 and 80 years old (Figure 2) displays the mortality rate for the same cases across age by decade with the mortality increasing from 0.7% in the 40 - 49 range to 16.1% in the age ≥ 80 range.

Table 1

	2006	2007	2008	2009	2010	All Years
	Year
Total Patients	1,720	2,013	1,867	2,137	2,234	9,971
Total Deaths	141	82	143	127	120	613
Mortality (%)	8.2	4.1	7.6	5.9	5.4	6.1
Mean Age (Years)	63.7	63.5	63.6	63.4	62.7	63.3
Male (%)	78.8	81.8	83.2	81.7	80.3	81.2
Female (%)	21.2	18.2	16.8	18.3	19.7	18.8
LOS (Days)	17.8	16.2	17.2	16.1	17.3	16.9
Charges ($)	$122, 278	$147,016	$158,663	$177,236	$190,860	$ 161,229

Table 1:Characteristics of all patients who underwent esophagectomy from 2006 through 2010.

Table 1
Characteristics of all patients who underwent esophagectomy from 2006 through 2010.

Table 2

	< 55	55-74	≥75	p-value
Age Group (Years)
Total Patients	1,909	6,670	1,391
Mortality (%)	2.5	6.3	10.3	< 0.01*
Length of Stay (Days)	15.3	16.8	19.4	< 0.01*
Routine Home Discharge (%)	45.2	32.8	15.8	< 0.01*
Discharged with Home Health Assistance (%)	46.4	45.4	41.2	< 0.01*
Discharged to Skilled Nursing Facility (%)	5.1	14.5	31.6	< 0.01*
Transfer to Other Hospital (%)	0.8	0.9	1.1	0.74
Charges ($)	146,605	157,612	198,639	< 0.01*

Table 2: Characteristics of post-esophagectomy outcomes based on three age groups.

Table 2
Characteristics of post-esophagectomy outcomes based on three age groups.

Discussion

Esophagectomy for patients with esophageal cancer remains a complex surgery with significant morbidity, mortality despite advancements in surgical technique and post-operative care [1]. Although the prevalence of esophageal cancer in the United States has remained static over the last decade, the Surveillance, Epidemiology, and End Results (SEER) website projects 16,910 new cases for the year 2016 [3]. At the same time, the United States population is aging. As a result, an increasing number of senior esophageal cancer patients are presenting for consideration of surgery [4]. Is it reasonable to offer surgery to esophageal cancer patients regardless of age, or is there a point at which the risk-benefit odds are tipped against operative treatment? The purpose of this study was to assess cost, risks, and discharge disposition of esophageal cancer patients undergoing surgery as a function of age. Armed with this information, patient selection for surgery will be enhanced, and patients better informed about what they can expect for both surgery and early recovery.
In our study the NIS database was searched to identify all patients undergoing esophagectomy for cancer for the period 2006 through 2010. The search excluded upper thoracic and cervical esophageal cancers to ensure patients with primary head and neck malignancies were not included. This period was selected as it gave complete date over a five year period. The overall patient characteristics, by year, are shown in (Table 1). The number of surgery patients remains relatively constant at approximately 2000 per year consistent with the SEER esophageal cancer prevalence data. Patient characteristics are consistent with published data and show a mean age is 63.3 years, and a male predominance (81.2%), Mean LOS and mortality was 16.9 days and 6.1% (4.1% - 8.2%) respectively. The cost of care increased each year. (Figure 1) shows the age distribution of the entire cohort of patients. Twenty-nine percent of patients were 70 years of age or older (Table 2) summarizes post surgical outcome by age. By far the 55 - 74 year group was the largest as expected, and patients who were >75 years represented 13% of the total cohort. Operative mortality increased significantly, almost exponentially, by age (Figure 2). Mortality for patients 80 years of age or older was a remarkable 16.1%. Both LOS and hospital cost rose significantly by age, but less dramatically than mortality. One of the most interesting findings in this review was data on post-discharge disposition. For the purposes of this study, we defined a routine discharge as one in which there was no need for skilled nursing facility or home health support. Remarkably, even for the < 55 years group, less than half of patients (45.2%) had a routine discharge. This fell to only 15.8% for patients over 75 years of age. Only 5.1% of < 55 group needed transfer to skilled nursing facility compared with almost a third (31.6%) for patients over 75 years of age. All of these results were significant. Transfer to another acute care facility was uncommon for all age groups. Furthermore, the cost of all of post-discharge care was not included in the cost data listed which was for acute care hospital charges only. This means that the cost of care listed in this database greatly underestimated the overall cost of care especially for older patients.
Currently many factors come into play when considering surgery for esophageal cancer patients including surgical morbidity and mortality, LOS, cost of care, post-discharge disposition, and time to return to independent activity, quality of life, and survival. All of this must be further weighted against non-operative treatment options.
Assessing surgical risk, especially when it becomes prohibitive, can be difficult and controversial. Boyd and Jackson emphasize that surgical risk varies according to the observer such as patient, family, nurse, surgeon, anesthesiologist, intensivist, and administrator. They propose a clinical definition of high risk as >5% mortality, or 2x the mortality for the general population. Extremely high risk would be a surgical mortality of >20% [5]. Our results (Figure 2) show that patients age 70-79 would therefore be considered high risk with surgical mortality of 9.1%, and patients over 80 years (mortality 16.1%) are close to being “extremely” high risk.
In our study, age was the only variable compared with outcome. This was a fortuitous variable to track as age, either alone or indirectly, is central to most published methods of pre-operative risk assessment. The American Society of Anesthesiologist (ASA) class system has long been a useful clinical tool. It is based not on age but on clinical status and co-morbidities. However, the probability of accumulating co-morbidities and developing declining clinical performance rises with age. Therefore, ASA class is indirectly related to age.
Fuchs et al. [6] developed a risk assessment scoring system specifically for esophagectomy patients. The scoring system assigns points to patient factors including age, co-morbidities, tumor cell type, hospital volume, and surgical approach. The Society of Thoracic Surgeons database identified congestive failure, functional status, smoking (current or former history), three incision esophagectomy, squamous cell pathology, and age >65 years as factors increasing patient risk for esophagectomy [7]. Park et al.[8] reported emergency surgery and increased frailty index increased risk. The frailty index is a method used to determine a patient’s biologic age as opposed to chronologic age. Fischer et al. [9] identified co-morbidities, ECOG performance status, and ASA class as risk factors for esophagectomy.
Again, both ECOG functional status and ASA class are indirectly related to age. In a cohort of elderly cancer patients (>75 years old) undergoing esophagectomy, Yamamoto et al. [10] observed post operative delirium in 26%. Delirium was associated with other complications and increased LOS. The likelihood of delirium could be predicted by pre-surgery comprehensive geriatric assessment (CGA). The CGA is composed of 5 test elements that would each be adversely affected by age.
Furthermore, similar to our study, the incidence of being discharged to a rehabilitation facility for patients with and without delirium was 30.4% vs. 13.6% respectively. Several authors have documented the consequences and costs associated with operating on high risk patients and recommend careful consideration when evaluating such patients for surgery [11-13]. Our study has several limitations. It is a retrospective study that dates back to 2006. It uses a broad national database and does not reflect individual surgeon, institution, or patient results. Only a single variable (age) is tracked. However, it does not change the fact that this data, and supporting literature, clearly show that advancing age is a well documented risk factor for esophageal cancer patients considering surgery. Furthermore, age ≥75 years of age is associated with significantly increased risk. This fact, and the high likelihood of need for postdischarge home or skilled nursing care in elderly patients, should be part of the discussion of any esophagectomy surgical consent.

Conclusion

Post-esophagectomy in-patient mortality, LOS, inpatient charges and the need for post-discharge to skilled nursing facility increase significantly with age. Inpatient charges alone underestimate the overall cost of esophagectomy care. These results should help in selecting esophageal cancer patients for surgery and communicating post-operative expectations.

Research Article