Measuring What Matters to People Having Surgery
A comfortable, pain-free recovery
Avoiding complications after surgery
Avoiding the need to go into a nursing home
Avoiding the need to be re-admitted to hospital
Returning to their own home as soon as possible
more days at home in the first month after surgery
Professor Paul Myles
The Alfred Hospital-Monash University Department of Anaesthesiology and Perioperative Medicine has a special interest in measuring what matters for people having surgery – having a comfortable, pain-free recovery, avoiding complications such as chest infection or blood clots, and getting back to normal as quickly as possible.
Our patients tell us that an early return home after surgery is important and highly valued. They want to get back to their family, in their own house and their own bed, using their own bathroom and eating their own food. Looking forward to a healthy future.
That is, “more days at home and living well, for longer” is their goal, and it can be easily measured. Hospitals are striving to reduce complications after surgery and minimize healthcare costs. That is, to provide high value care. Complications after surgery increase hospital stay, and therefore increase healthcare costs.
The duration of hospital stay after surgery has often been used as a proxy measure of quality care, but it can be misleading if people are discharged too early and need to be re-admitted days or weeks later, or if they are discharged to a nursing home, of even if they die – each of these will shorten hospital stay but do NOT indicate good quality of care.
For people having surgery, we have adapted this concept of healthy recovery to more “days alive and at home within 30 days after surgery”, or DAH-30 for short. We then validated its value as a quality of care indicator in different countries, big and small hospitals, and across many types of surgery. This included the Alfred Hospital in Melbourne in which we studies more than 2,000 people, and also at the Karolinska group of hospitals in Sweden where we studies more than 600,000 people having surgery.
We found that DAH-30 was less in:
- the elderly
- people with chronic health problems
- those recovering from more complex surgery
- those suffering serious postoperative complications
- those admitted to a rehabilitation hospital or nursing home
- those who died
People spending less than 1 week at home in the first month after surgery had a nearly 7-fold greater risk of death up to 1 year after surgery.
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- Myles PS, Shulman M, Heritier S, et al. Validation of days at home as an outcome measure after surgery: a cohort study of clinical trial hospital, discharge and 30-day follow-up data. BMJ Open (2017): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629653/
- Bell M, Eriksson LI, Svensson T, et al. Days at home after surgery: an integrated and efficient outcome measure for clinical trials and quality assurance. EClinicalMedicine (2019): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610780/
- Jerath A, Austin PC, Ko DT, et al. Socioeconomic Status and Days Alive and Out of Hospital after Major Elective Noncardiac Surgery: A Population-based Cohort Study. Anesthesiology (2020): https://pubs.asahq.org/anesthesiology/article/132/4/713/108873/Socioeconomic-Status-and-Days-Alive-and-Out-of
- Jerath A, Austin PC, Wijeysundera DN. Days Alive and Out of Hospital: Validation of a Patient-centered Outcome for Perioperative Medicine. Anesthesiology (2019): https://pubs.asahq.org/anesthesiology/article/131/1/84/18061/Days-Alive-and-Out-of-HospitalValidation-of-a
- Plenge U, Parker R, Davids S, et al. Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study. BMC Musculoskelet Disord (2020): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643442/
How to Calculate DAH-30
DAH-30 is calculated using mortality and hospitalisation data from the date of the index surgery (= Day 0). For example, if a patient died on day 2 after their surgery whilst still an inpatient, they would be assigned zero (0) days at home; if a patient was discharged from hospital on Day 6 after surgery but was subsequently re-admitted for 4 days before their second hospital discharge, then they would be assigned a DAH-30 value of 20. If a patient has complications and spends 16 days in hospital, and then is transferred to a nursing facility for rehabilitation, and spend 24 days there before finally being discharged to their own home, they would be assigned a DAH-30 value of zero (0), even though 30-16-24 = -10 because the minimum value of DAH-30 should be zero. If a patient dies within 30 days of surgery, irrespective of whether they have spent some time at home, DAH-30 will be scored as zero (0).
That is, DAH-30 captures the impact of any complications after surgery, including those that are not otherwise detected or reported, or occur following hospital discharge.
The Importance of DAH-30
DAH-30 is a valuable surgical outcome measure that accounts for the initial hospital stay, readmission due to post-discharge complications, discharge to institutional care, and early deaths.
DAH-30 reflects personal, social and economic benefit. It is easily measured and can be used to compare results of both individual doctors and hospitals. Efforts should be put in place to improve this patient-centred outcome in surgical practice.