F. J. Hwang2, S. Pentakota2, R. Singh2, A. Berlin2, A. Mosenthal2 2Rutgers New Jersey Medical School,Surgery,Newark, NJ, USA 1University Of Medicine And Dentistry Of New Jersey,General Surgery,Newark, NJ, USA
Introduction: Patients with dementia who develop acute abdominal emergencies have high risk of morbidity and mortality. Accurate prognostication about outcomes would be helpful in order to make improved patient-centered decisions. Little is known on palliative care (PC) utilization in patients with dementia in need of emergency abdominal surgery. The purpose of this study is to characterize outcomes and factors associated with PC utilization for patients with dementia presenting with acute abdominal emergencies.
Methods: The National Inpatient Sample database between the years of 2009 and 2013 was queried using ICD-9 codes for patients > 50 years with dementia and acute abdomen (bowel ischemia, obstruction, or perforation). Study variables were patient demographics and hospital information. Outcomes included in-hospital mortality, discharge disposition, length of stay, total charges, and receipt of palliative care. Multivariable logistic regression analysis was used to identify factors associated with receiving PC.
Results: 6,867 patients met the inclusion criteria. Among these patients, 22% (N=1530) underwent surgery; 16% (N=1090) died in hospital; 49% (N=3360) were discharged to a facility; and 10% (N=717) received palliative care. 29% (N=314) of those who died in hospital received PC. PC utilization increased over the study time period (7% in 2009 to 12% in 2013). Patients older than 90 received more frequent PC compared to those aged 60 to 90 years (p<0.01). Those from the highest socioeconomic status were 1.7x more likely to receive PC compared to those from the lowest quartile (p<0.01). Patients who had perforation were 2.6x and 1.6x more likely to receive PC compared to those with obstruction and bowel ischemia, respectively (p<0.01). Non-operative management was associated with 2.7x increase in receiving PC vs patients undergoing surgery (p<0.01). PC was associated with lower median length of stay (4 days vs 6 days) and lower hospital charges ($26,800 vs $33,000) (p<0.01).
Conclusion: Patients with dementia and acute abdomen have high in-hospital mortality and rate of discharge to dependent care, regardless of surgical interventions. Despite this, few receive palliative care. Receipt of PC was associated with age >90, higher socioeconomic status, and having perforation as the indication for surgery. Those who had PC had fewer surgical interventions and lower intensity of treatment, suggesting that patients and their families who received PC may choose a less aggressive form of treatment in the setting of poor prognosis. The high rate of unmet palliative care needs in this population presents an opportunity for improvement in surgical care.