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Original Investigation
October 7, 2020

Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment

Author Affiliations
  • 1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Division of General Surgery, Sunnybrook Health Sciences Centre–Odette Cancer Centre, Toronto, Ontario, Canada
  • 3Sunnybrook Research Institute, Toronto, Ontario, Canada
  • 4ICES, Toronto, Ontario, Canada
  • 5Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
  • 6Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 7Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
  • 8Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 9Bruyère Research Institute, Ottawa, Ontario, Canada
JAMA Surg. Published online October 7, 2020. doi:10.1001/jamasurg.2020.3754
Key Points

Question  How much time do older adults spend at home after receiving surgical treatment for cancer?

Findings  In this population-based cohort study of 82 037 patients 70 years or older, most patients spent more than 98% of their time at home during the 5 years after resection for cancer. The probability of having high time at home (defined as ≤14 institution days over 1 year) was 70.3% at postoperative year 1 and 53.2% at postoperative year 5.

Meaning  This study suggests that time at home data could be used for preoperative counseling regarding surgical cancer treatment to support decision-making, enhance preparedness for the surgical procedure, and set expectations for long-term outcomes.

Abstract

Importance  Functional outcomes are central to cancer care decision-making by older adults.

Objective  To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure.

Design, Setting, and Participants  This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018.

Main Outcomes and Measures  The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used.

Results  A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time.

Conclusions and Relevance  This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.

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