Surgery for pelvic organ prolapse (POP) among older women is common and a growing number of older women are frail, meaning that they experience a decrease in physiological capacity that predisposes them to stressors such as surgery.  The effects of frailty on surgical outcomes in older women undergoing surgery for pelvic organ prolapse (POP), however, are unknown.  The purpose of this study is to compare short- and long-term surgical outcomes between nursing home residents (who are by definition frail) and matched community-dwelling older adults undergoing surgery for POP.

This is a retrospective cohort study of women >/=65 years of age undergoing different types of POP repairs (anterior/posterior repairs, apical repairs and colpocleisis procedures) between 2007 and 2012 using Medicare Inpatient claims (MedPAR file) and the Minimum Data Set (MDS file) for Nursing Home Residents.  Long-stay nursing home residents undergoing POP surgery were identified in the MDS and propensity score matched (1:2) to community dwelling older individuals based on procedure type, age, race, and Charlson Score.  Linear regression models were created to determine the relative risk of hospital length of stay >/=3 days and 30-day complications between the two groups.  Kaplan Meier curves were created comparing 1-year mortality between groups.

There were 804 nursing home residents and 1606 matched community-dwelling older adults who underwent POP surgery and were included in our analyses.  Among the study cohort, 62.3% had anterior/posterior repairs, 14.8% had apical repairs, and 22.9% had colpocleisis procedures.  Mean age of the study cohort was 79.7 years, 88.7% of the cohort was white, and 9.1% had a Charlson Score >/=3.  Mean hospital length of stay was 3.4 days for nursing home residents, compared to 2.1 days for community-dwelling older adults (p<.0.0001).  Thirty-day complications were 16.2% among nursing home residents compared to 3.9% among community dwelling older adults (p<0.0001).  In the year following surgery, nursing home residents experienced a mean of 1.6 hospital readmissions compared to 0.3 hospital readmissions among community-dwelling older adults (p<0.0001).  Nursing home residents demonstrated statistically significant increased relative risks for hospital length of stay ≥3 days [40.5% vs 19.8%, adjusted RR 2.20 (95% CI 1.78-2.30)] and 30-day complications [16.2% vs 3.9%, aRR 4.11 (95% CI 3.08-5.48)] compared to community-dwelling older adults.  Kaplan Meier curves illustrating significantly higher 1-year mortality for nursing home residents are shown in the Figure (p<0.0001).

Despite matching on several demographic characteristics, nursing home residents demonstrated worse outcomes in terms of hospital length of stay, 30-day complications, and 1-year mortality, compared to community-dwelling older adults.

These findings illustrate that frailty adds additional surgical risk, beyond age, race and comorbidity, among older adults and should be considered during surgical decision-making.