Original Investigation
October 23, 2024
Long-Term Trajectories of Postoperative Recovery in Younger and Older Veterans
Michael A. Jacobs, Carly A. Jacobs, Orna Intrator, et al
JAMA Surg. Published online October 23, 2024. doi:10.1001/jamasurg.2024.4691
Question What do long-term postoperative recovery trajectories look like?
Findings This cohort study (378 682 cases) included 5 postoperative recovery trajectories. Trajectories included routine, slow, and protracted recoveries, loss of independence, and chronic dependence; these included trajectories were heavily associated with days elsewhere than home and various preoperative and operative risk factors.
Meaning In this study, trajectory models demonstrated clinically meaningful differences in postoperative recovery that should inform surgical decision-making.
Abstract
Importance Major surgery sometimes involves long recovery or even permanent institutionalization. Little is known about long-term trajectories of postoperative recovery, as surgical registries are limited to 30-day outcomes and care can occur across various institutions.
Objective To characterize long-term postoperative recovery trajectories.
Design, Setting, and Participants This retrospective cohort study used Veterans Affairs (VA) Surgical Quality Improvement Program data (2016 through 2019) linked to the Residential History File, combining data from the VA, Medicare/Medicaid, and other sources to capture most health care utilization by days. Patients were divided into younger (younger than 65 years) or older (65 years or older) subgroups, as Medicare eligibility is age dependent. Latent-class, group-based trajectory models were developed for each group. These data were analyzed from February 2023 through August 2024.
Exposure Surgical care in VA hospitals.
Main Outcomes and Measures Days elsewhere than home (DEH) were counted in 30-day periods for 275 days presurgery and 365 days postsurgery.
Results A 5-trajectory solution was optimal and visually similar for both age groups (cases: 179 879 younger [mean age (SD) 51.2 (10.8) years; most were male [154 542 (83.0%)] and 198 803 older [mean (SD) age, 72.2 (6.0) years; 187 996 were male (97.6%)]). Most cases were in trajectories 1 and 2 (T1 and T2). T1 cases returned home within 30 days (younger, 74.0%; older, 54.2%), while T2 described delayed recovery within 30 to 60 days (younger, 21.6%; older, 35.5%). Trajectory 3 (T3) and trajectory 4 (T4) were similar for the first 30 days postsurgery, but subsequently separated with T3 representing protracted recovery of 6 months or longer (younger, 2.7%; older, 3.8%) and T4 indicating long-term loss of independence (younger, 1.3%; older, 5.2%). Few (trajectory 5) were chronically dependent, with 20 to 30 DEH per month before and after surgery (younger, 0.4%; older, 1.3%).
Conclusions and Relevance In this study, trajectory models demonstrated clinically meaningful differences in postoperative recovery that should inform surgical decision-making. Registries should include longer-term outcomes to enable future research to distinguish patients prone to long-term loss of independence vs protracted, but meaningful recovery.
