Patient Frailty and Discharge Disposition Following Radical Cystectomy

Background: Patients with bladder cancer who are treated with cystectomy are at high risk for complications and prolonged length of stay. This population tends to be of advanced age with underlying comorbidities, and thus more likely to have decreased physiologic reserve (ie, frailty). Our objective was to evaluate the relationship between frailty and discharge disposition for patients with bladder cancer treated with cystectomy.

Materials and methods: Using data from the National Surgical Quality Improvement Program, we identified patients with bladder cancer undergoing cystectomy (2011-2014). Our exposure of interest was frailty, based on the 11-point modified Frailty Index (mFI). Patients were deemed robust (mFI = 0), pre-frail (mFI = 0.09-0.18), or frail (mFI ≥ 0.27). Our outcome of interest was discharge disposition defined as home, skilled nursing facility, and rehabilitation dichotomized as home versus non-home for multivariable logistic regression analysis. We then generated predicted probabilities of non-home discharge based on frailty and in-hospital complications.

Results: Among 4330 patients treated with radical cystectomy, 32.8% were robust, 65.1% were pre-frail, and 2.2% were frail. Overall, 86.2% were discharged home, 4.4% to a rehabilitation facility, and 9.4% to a skilled nursing facility. Frail patients were more likely to be discharged to non-home care (vs. robust, odds ratio, 2.33; 95% confidence interval, 1.34-4.03), which was independent of whether they experienced a major complication prior to discharge.

Conclusion: Frailty is a significant predictor of non-home discharge following radical cystectomy. This finding was independent of inpatient complications. These data will assist providers in setting patient expectations and have important implications for allocating postoperative resources.