title: Mortality after emergency surgery continues to rise after discharge in the elderly: Predictors of 1-year mortality.
abstract: BACKGROUND
  It is known that emergency surgery in the elderly is associated with high short-term mortality, but longer-term outcomes are not well described. We hypothesized that 30-day mortality may underestimate the true operative mortality experienced in this cohort. The purposes of this study were to characterize postoperative mortality rates extending to 1 year and to identify preoperative predictors of 1 year mortality after emergency abdominal surgery.
  
  
  METHODS
  We retrospectively reviewed the records of all patients older than 70 years who underwent emergency abdominal surgery at a major teaching hospital between 2006 and 2011. Demographics, preoperative physiology, prehospital status, body mass index, laboratory values, Charlson scores, comorbid conditions, American Society of Anesthesiologists classification, and operative details were recorded. The primary end point was 1-year mortality. Complementary log-log binary regression was used to determine independent predictors of death. Model discrimination was evaluated using the c statistic.
  
  
  RESULTS
  A total of 390 patients met our inclusion criteria. The mean age was 79 years, and 56% were women. Postoperative mortality was 16.2% at 30 days and 32.5% at 1 year, reflecting a doubling of mortality over 11 months. Independent preoperative predictors of 1-year mortality were Charlson score of 4 or higher (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.38-2.34), American Society of Anesthesiologists class of 4 or higher (HR, 1.66; 95% CI, 1.22-2.21), albumin less than 3.5 (HR, 1.71; 95% CI, 1.31-2.28), and body mass index lower than 18.5 (HR, 3.36; 95% CI, 1.48-6.86). The c statistic was 0.81.
  
  
  CONCLUSIONS
  The 1-year mortality after emergency surgery in the elderly is significantly higher than that at 30 days. We identified a constellation of preoperative clinical markers that were highly predictive of this poor late outcome. The presence of these findings in the emergency setting should prompt preoperative discussion about treatment goals and encourage surgeons to set realistic expectations about outcomes with the patient and family. Future studies will develop a clinical scoring tool that can be applied at the bedside to provide more effective counseling for this high-risk population.
  
  
  METHODS
  Epidemiologic/prognostic study, level III; therapeutic study, level IV.
authors: From the Brigham and Women's Hospital (E.L.R., Z.C., O.A.O., G.R., S.R.L., A.S., G.K.); and Harvard Medical School (C.C.), Boston, Massachusetts; and Robert Wood Johnson University Hospital (M.S., J.S.H.), New Brunswick, New Jersey.
authors: Erika L
authors: EL
authors: Rangel
authors: Zara
authors: Z
authors: Cooper
authors: Olubode A
authors: OA
authors: Olufajo
authors: Gally
authors: G
authors: Reznor
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Ali
authors: A
authors: Salim
authors: Gifty
authors: G
authors: Kwakye
authors: Christopher
authors: C
authors: Calahan
authors: Mohammad
authors: M
authors: Sarhan
authors: Joseph S
authors: JS
authors: Hanna
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004630:Emergencies; D005260:Female; D006801:Humans; D008297:Male; D010351:Patient Discharge; D011183:Postoperative Complications / Q000401:mortality*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis