Days Alive and Out of Hospital: Validation of a Patient-centered Outcome for Perioperative Medicine.

BACKGROUND: Days alive and out of hospital is a potentially useful patient-centered quality measure for perioperative care in adult surgical patients. However, there has been very limited prior validation of this endpoint with respect to its ability to capture differences in patient-level risk factor profiles and longer-term postoperative outcomes. The main objective of this study was assessment of the feasibility and validity of days alive and out of hospital as a patient-centered outcome for perioperative medicine.
METHODS: The authors evaluated 540,072 adults undergoing 1 of 12 major elective noncardiac surgical procedures between 2006 to 2014. Primary outcome was days alive and out of hospital at 30 days, secondary outcomes were days alive and out of hospital at 90 days and 180 days. Unadjusted and risk-adjusted adjusted analyses were used to determine the association of days alive and out of hospital with patient-, surgery-, and hospital-level characteristics. Patients with days alive and out of hospital at 30 days values less than the tenth percentile were also classified as having poor days alive and out of hospital at 30 days. The authors then determined the association of poor days alive and out of hospital at 30 days with in-hospital complications, poor days alive and out of hospital at 90 days (less than the tenth percentile), and poor days alive and out of hospital at 180 days (less than the tenth percentile).
RESULTS: Overall median (interquartile range) days alive and out of hospital at 30, 90, and 180 days were 26 (24 to 27), 86 (84 to 87), and 176 (173 to 177) days, respectively. Median days alive and out of hospital at 30 days was highest for hysterectomy and endovascular aortic aneurysm repair (27 days) and lowest for upper gastrointestinal surgery (22 days). Days alive and out of hospital at 30 days was associated with clinically sensible patient-level factors (comorbidities, advanced age, postoperative complications), but not measured hospital-level factors (academic status, bed size). Of patients with good days alive and out of hospital at 30 days, 477,163 of 486,087 (98%) and 470,093 of 486,087 (97%) remained within this group (greater than the tenth percentile) at days alive and out of hospital at 90 and 180 days.
CONCLUSIONS: Days alive and out of hospital is a feasibly measured patient-centered outcome that is associated with clinically sensible patient characteristics, surgical complexity, in-hospital complications, and longer-term outcomes. Days alive and out of hospital forms a novel patient-centered outcome for future clinical trials and observational studies for adult surgical patients.