© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Clin Transplant 2015: 29: 581–587 DOI: 10.1111/ctr.12556
Clinical Transplantation
Factors affecting discharge destination following lung transplantation Tang M, Mawji N, Chung S, Brijlal R, Lim Sze How JK, Wickerson L, Rozenberg D, Singer LG, Mathur S, Janaudis-Ferreira T. Factors affecting discharge destination following lung transplantation. Abstract: Background: Lung transplant (LT) recipients requiring additional care may be referred to inpatient rehabilitation prior to discharge home. This study seeks to describe discharge destinations following LT, compare the characteristics of patients discharged to different destinations, and identify the predictors of discharge destination. Methods: Retrospective study of 243 LT recipients who survived to hospital discharge between 2006 and 2009. LT recipients were compared based on discharge destination on data pertaining to demographics, clinical characteristics, and healthcare utilization. Results: Of the 243 recipients, 197 (81%) were discharged home, 42 (17%) to inpatient rehabilitation, and 4 (2%) to other medical facilities. Age, pulmonary diagnosis, most recent six-minute walk distance (6MWD) prior to transplant, pre-transplant mechanical ventilation, priority listing status, pre- and post-transplant intensive care unit length of stay (ICU LOS), post-transplant LOS, total LOS, and participation in pre-transplant rehabilitation were statistically different between patients that were discharged home versus inpatient rehabilitation. Age, most recent 6MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be independent predictors of discharge destination. Conclusion: Clinical factors can help identify patients more likely to require inpatient rehabilitation. Identification of these factors has the potential to facilitate early discharge planning and optimize continuity of care.
Min Tanga, Nadir Mawjia, Samantha Chunga, Ryan Brijlala, Jonathan Ken Lim Sze Howa, Lisa Wickersona,b, Dmitry Rozenbergb,c, Lianne G. Singerb,c, Sunita Mathura,d and Tania Janaudis-Ferreiraa,d a
Department of Physical Therapy, Faculty of Medicine, University of Toronto, bLung Transplant Program, Toronto General Hospital, University Health Network, cDepartment of Medicine, Division of Respirology, University of Toronto and dRespiratory Medicine, West Park Health Centre, Toronto, ON, Canada Key words: discharge planning – lung transplantation – rehabilitation Corresponding author: Tania JanaudisFerreira, West Park Healthcare Centre, Respiratory Medicine, 82 Buttonwood Avenue, Toronto, ON, M6M 2J5, Canada. Tel.: (416) 243 3600, ext. 2518; fax: (416) 243 3747; e-mail: [email protected] Conflict of interest: None. Accepted for publication 23 April 2015
Every year, an increasing number of individuals with end-stage lung disease undergo lung transplantation (LT) to improve survival and healthrelated quality of life (1, 2). In recent years, there has been a shift in the demographics of LT recipients toward an older and more ill population, which may require a longer hospitalization and additional care such as post-transplant inpatient rehabilitation (1, 3). In Canada, most LT programs recommend pre-transplant outpatient rehabilitation and provide mandatory post-transplant outpatient rehabilitation (4). LT recipients requiring additional care may be referred to an inpatient rehabilitation program (5). Identification of factors that affect discharge destination could help to facilitate discharge planning from the acute care hospital and initiate inpatient rehabilitation sooner (6, 7). However, there are no previous studies that
have examined the factors that may be associated with discharge to home vs. other destinations (e.g., inpatient rehabilitation) following acute care hospital stay in LT recipients. Based on the previous literature in solid organ transplant (2, 3, 6, 8–18), we hypothesized that the following factors would be associated with discharge destination: age at the time of transplant, body mass index (BMI), pre-transplant diagnosis, priority status for transplant, transplantation from mechanical ventilation, participation in pre-transplant rehabilitation, pre-transplant functional exercise capacity, type of transplant, pre- and posttransplant intensive care unit (ICU) length of stay (LOS), and total LOS. The objectives of this study were to (i) describe the discharge destinations after LT, (ii) compare the characteristics of patients discharged to different destinations, and
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(iii) identify the predictors of discharge to inpatient rehabilitation. Patients and methods
Ethics approval was obtained from the hospital and university’s research ethics board. A retrospective chart review was conducted on individuals (aged ≥ 18 yr) who underwent a first single, double LT, or heart–lung transplant at Toronto General Hospital, Toronto, Ontario, Canada, between June 01, 2006, and June 30, 2009, using Electronic Health Records and Organ Transplant Tracking Record. The study period was selected based on a pre-existing database containing LT recipients between 2006 and 2009. Recipients who received re-transplantation within the study period were excluded along with those who died during their post-LT acute hospital stay. The following data were extracted: age at the time of transplant, sex, primary pulmonary diagnosis, pre-transplant functional exercise capacity (measured by the most recent six-minute walk test (6MWT) prior to transplant), most recent Canadian listing urgency status at the time of transplantation, BMI, transplantation from mechanical ventilation, pre- and post-transplant ICU LOS, post-transplant hospital LOS, total hospital LOS, type of transplant, waitlist time, participation in pre-transplant outpatient rehabilitation, and recipients’ discharge destination. Canadian listing priority is based on a subjective determination of illness severity and disease trajectory, rather than a numerical scoring system such as the Lung Allocation Score. Discharge destinations were categorized as home—recipient’s private dwelling within the community with or without Community Care Access Centre (home care) services; inpatient rehabilitation at St. John’s Rehab Program of Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (5); or other medical facility—community hospital closer to patient’s home, nursing home, long-term care, etc. St. John’s Rehab Program of Sunnybrook Health Sciences Centre has a dedicated inpatient rehabilitation program for solid organ transplant recipients. Criteria for admission to this specialized program are as follows: (i) medically stable with no significant fluctuations in medical status within 72 h; (ii) motivated to participate in rehabilitation, has active rehabilitation goals, and is able to participate in two sessions of active rehabilitation therapy 5–7 d a week; (iii) able to sit unsupported for a minimum of 30 min; (iv) cognitive abilities and state of mental health support participation in active rehabilitation; and (v) nonventilated breathing. Special needs such as IV ther-
582
apy, oxygen therapy, tracheotomy, intermitted tube feeds, or ostomy are considered on a case-bycase basis. The standard practice at Toronto General Hospital is for patients to participate in an outpatient rehabilitation program up to three months post-transplant. A chart abstraction instrument was created and assessed for inter-rater reliability among four investigators (MT, NJ, SC, and RB). Two investigators reviewed each chart and extracted the data independently, and the data were entered by a fifth investigator (JLSH). Inconsistencies between the data sets and outliers were verified by confirming with the charts and corrected prior to data analysis. To address the first and second objectives, statistical analyses were performed using Statistical Package for the Social Sciences software (SPSS; version 20; IBM, Armonk, NY, USA). Continuous data (e.g., age, LOS, 6MWD) were first tested for normality using the Shapiro–Wilks test. Descriptive statistics were expressed as frequency and percentage, mean and standard deviation (SD, normally distributed), or median and interquartile range (IQR, non-normally distributed). For normally distributed variables, chi-square (v2) analysis was used to compare the factors between LT recipients discharged home and inpatient rehabilitation; those discharged to other medical facilities were excluded from comparative analysis due to the small sample size. Mann–Whitney U-test was used to compare the two groups on non-normally distributed, continuous variables. Independent samples t-test was used to test for differences for normally distributed variables. To address the third objective, statistical analyses were performed with R version 3.0.2 (open source statistical software). A multivariable logistic regression analysis was conducted. The variables were selected a priori based on the literature and tested for collinearity. There was significant collinearity between age and diagnosis, as well as total LOS and ICU LOS (preand post-transplant), and thus they were analyzed in separate models. The model with the best predictive value is presented in Table 2. A p-value of ≤0.05 was considered significant for all analyses. Results Sample characteristics
Within the study period, 274 LT recipients were identified. Eleven recipients who received re-transplantation, one recipient who was less than 18 yr old, and 19 who died during their post-LT acute hospital stay were excluded from the analysis. A total of 243 LT recipients were included in the
Discharge destination after lung transplant analysis. The median age of LT recipients at transplant was 54 yr (IQR = 40–61 yr). The majority of LT recipients were male (59.7%, n = 145). The two most common pre-transplant diagnoses were chronic obstructive pulmonary disease (COPD) (34.7%; n = 84) and interstitial lung disease (ILD) (33%; n = 81), followed by cystic fibrosis (CF) (20.2%; n = 49). The majority of LT recipients received double LT (81%; n = 196), followed by single LT (15%; n = 37) and heart LT (4%; n = 10). The median of the most recent 6MWD prior to transplant was 296 m (IQR = 216–373). Fifteen LT recipients (6%) required mechanical ventilation as a bridge to transplant. The median post-transplant ICU LOS was five d (IQR = 3– 16), and the median total post-transplant acute care hospital LOS was 22 d (IQR = 16–37). Following LT, the majority of recipients were discharged home (81%; n = 197) or to inpatient rehabilitation (17%; n = 42). A small percentage of recipients were discharged to other medical facilities (2%, n = 4). These recipients were excluded from analyses due to the small sample size. Comparison between LT recipients discharged home and inpatient rehabilitation
LT recipients who were discharged home were younger (53 yr, IQR = 38–61) than recipients discharged to inpatient rehabilitation (57 yr, IQR = 50–64, p = 0.043). Individuals with CF and COPD were more likely to be discharged home, whereas those with ILD and PAH were more likely to be discharged to inpatient rehabilitation (p < 0.001) (Table 1). A greater proportion of recipients who required mechanical ventilation as a bridge to transplantation were discharged to inpatient rehabilitation compared to recipients who did not (p < 0.001). Priority status for transplant (at time of transplantation) was also different between home and inpatient rehabilitation groups, with higher urgency status 2 and rapidly deteriorating candidates more likely to require discharge to inpatient rehabilitation (p < 0.001) (Table 1). Patients discharged home had better functional exercise capacity as measured by the most recent 6MWD before transplant than recipients who were discharged to inpatient rehabilitation (302 m, IQR = 223–402 vs. 250 m, IQR = 153–315, p < 0.05) (Table 1). Participation in pre-transplant rehabilitation differed between the two groups (home = 169 (yes) and 28 (no); rehabilitation = 24 (yes) and 18 (no); p < 0.001) (Table 1). The median post-transplant ICU LOS differed between the two groups (home = four d,
IQR = 3–11; rehabilitation = 22 d, IQR = 9–35; p < 0.001). A difference was also found for the median total LOS following LT (home = 20 d, IQR = 15–28; rehabilitation = 56 d, IQR = 43–88; p < 0.001) (Table 1). There was no difference between the rehabilitation group and home group in sex, BMI, waitlist time, or type of transplant (Table 1). Factors predicting discharge destination after lung transplantation
Results from the final model of the multivariable logistic regression analysis are shown in Table 2. Age, the most recent 6MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were the predictors of discharge destination following LT. For every 10 yr increase in age, the odds ratio to be discharged to inpatient rehabilitation was 1.93 (CI 1.26–2.95). For every 100 m increase in 6MWD, the odds ratio to be discharged to inpatient rehabilitation was 0.67 (CI 0.45–0.99). For pre-transplant mechanical ventilation and total hospital LOS (per one d), the odds ratios to be discharged to inpatient rehabilitation were 10.05 (CI 1.87–53.90) and 1.02 (CI 1.01–1.04), respectively. Discussion
The present study is the first to examine the factors affecting discharge destination following LT. Age, most recent 6MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be the significant independent predictors of discharge destination following LT. With growing evidence supporting the suitability of older patients for LT and an aging population, there is an overall upward trend in the number of older LT recipients over the past decade (2, 3, 19). There is evidence supporting age as a strong predictor of discharge destination in the liver transplantation population (6); the results from the present study also show that age is a predictor of discharge destination in the LT population. While previous studies examining the relationship between advancing age and LT outcomes have yielded inconclusive findings, older age is associated with lower aerobic capacity and sarcopenia (atrophy and weakness of the skeletal muscles) resulting in a decreased functional capacity which may impact discharge destination (3, 11). The 6MWT is a valid clinical outcome measure to assess the functional exercise capacity of individuals with advanced lung disease (20). Although previous studies have shown a relationship
583
584 0 (0–0; 1–110) 5 (3–16) 21 (16–37) 22 (16–43)
21 (8.6)/222 (91.4) 0 (0–0; 0–110) 4 (3–11) 19 (15–27) 20 (15–28)
7 (3.5)/190 (96.5)
57 (28.9) 94 (47.7) 46 (23.4) 302 (223–402) 228.5 (111–379) 23 (19–26) 169 (85.8)/28 (14.2)
31 (15.7) 160 (81.2) 6 (3.0)
37 (15.2) 196 (80.7) 10 (4.1) 61 (25.1) 111 (45.7) 71 (29.2) 296 (216–373) 221 (107–380) 23 (20–26) 197 (81)/46 (18.9)
72 (36.5) 48 (24.4) 60 (30.5) 6 (3.0) 11 (5.6)
53 (38–61) 121 (61.4)/76 (38.6)
84 (34.7) 49 (20.2) 81 (33.3) 12 (4.9) 17 (7.0)
54 (40–61) 145 (59.7)/ 98 (40.3)
Home (n = 197)
0 (0–3; 2–35) 22 (9–35) 52 (39–80) 56 (43–88)
13 (31)/29 (69)
4 (9.5) 13 (31.0) 25 (59.5) 250 (153–315) 181 (71–368) 25 (22–27) 24 (57)/18 (43)
6 (14.3) 32 (76.2) 4 (9.8)
9 (21.4) 1 (2.4) 21 (50) 5 (11.9) 6 (14.3)
57 (50–64) 22 (52.4)/20 (47.6)
Inpatient Rehabilitation (n = 42)
42 (11–91) 160 (26–304) 181 (27–386)
0 (0.0) /4 (100.0)
0 4 (100%) 0 297 (242–329) 363.5 (263–789) 17 (13–24) 4 (100)/0 (0)
0 4 (100) 0
3 (75) 0 0 1 (25) 0
54 (45–64) 2 (50)/2 (50)
Other (n = 4)
7 24
Missing
Clin Transplant 2015: 29: 581–587 DOI: 10.1111/ctr.12556
Clinical Transplantation
Factors affecting discharge destination following lung transplantation Tang M, Mawji N, Chung S, Brijlal R, Lim Sze How JK, Wickerson L, Rozenberg D, Singer LG, Mathur S, Janaudis-Ferreira T. Factors affecting discharge destination following lung transplantation. Abstract: Background: Lung transplant (LT) recipients requiring additional care may be referred to inpatient rehabilitation prior to discharge home. This study seeks to describe discharge destinations following LT, compare the characteristics of patients discharged to different destinations, and identify the predictors of discharge destination. Methods: Retrospective study of 243 LT recipients who survived to hospital discharge between 2006 and 2009. LT recipients were compared based on discharge destination on data pertaining to demographics, clinical characteristics, and healthcare utilization. Results: Of the 243 recipients, 197 (81%) were discharged home, 42 (17%) to inpatient rehabilitation, and 4 (2%) to other medical facilities. Age, pulmonary diagnosis, most recent six-minute walk distance (6MWD) prior to transplant, pre-transplant mechanical ventilation, priority listing status, pre- and post-transplant intensive care unit length of stay (ICU LOS), post-transplant LOS, total LOS, and participation in pre-transplant rehabilitation were statistically different between patients that were discharged home versus inpatient rehabilitation. Age, most recent 6MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be independent predictors of discharge destination. Conclusion: Clinical factors can help identify patients more likely to require inpatient rehabilitation. Identification of these factors has the potential to facilitate early discharge planning and optimize continuity of care.
Min Tanga, Nadir Mawjia, Samantha Chunga, Ryan Brijlala, Jonathan Ken Lim Sze Howa, Lisa Wickersona,b, Dmitry Rozenbergb,c, Lianne G. Singerb,c, Sunita Mathura,d and Tania Janaudis-Ferreiraa,d a
Department of Physical Therapy, Faculty of Medicine, University of Toronto, bLung Transplant Program, Toronto General Hospital, University Health Network, cDepartment of Medicine, Division of Respirology, University of Toronto and dRespiratory Medicine, West Park Health Centre, Toronto, ON, Canada Key words: discharge planning – lung transplantation – rehabilitation Corresponding author: Tania JanaudisFerreira, West Park Healthcare Centre, Respiratory Medicine, 82 Buttonwood Avenue, Toronto, ON, M6M 2J5, Canada. Tel.: (416) 243 3600, ext. 2518; fax: (416) 243 3747; e-mail: [email protected] Conflict of interest: None. Accepted for publication 23 April 2015
Every year, an increasing number of individuals with end-stage lung disease undergo lung transplantation (LT) to improve survival and healthrelated quality of life (1, 2). In recent years, there has been a shift in the demographics of LT recipients toward an older and more ill population, which may require a longer hospitalization and additional care such as post-transplant inpatient rehabilitation (1, 3). In Canada, most LT programs recommend pre-transplant outpatient rehabilitation and provide mandatory post-transplant outpatient rehabilitation (4). LT recipients requiring additional care may be referred to an inpatient rehabilitation program (5). Identification of factors that affect discharge destination could help to facilitate discharge planning from the acute care hospital and initiate inpatient rehabilitation sooner (6, 7). However, there are no previous studies that
have examined the factors that may be associated with discharge to home vs. other destinations (e.g., inpatient rehabilitation) following acute care hospital stay in LT recipients. Based on the previous literature in solid organ transplant (2, 3, 6, 8–18), we hypothesized that the following factors would be associated with discharge destination: age at the time of transplant, body mass index (BMI), pre-transplant diagnosis, priority status for transplant, transplantation from mechanical ventilation, participation in pre-transplant rehabilitation, pre-transplant functional exercise capacity, type of transplant, pre- and posttransplant intensive care unit (ICU) length of stay (LOS), and total LOS. The objectives of this study were to (i) describe the discharge destinations after LT, (ii) compare the characteristics of patients discharged to different destinations, and
581
Tang et al.
(iii) identify the predictors of discharge to inpatient rehabilitation. Patients and methods
Ethics approval was obtained from the hospital and university’s research ethics board. A retrospective chart review was conducted on individuals (aged ≥ 18 yr) who underwent a first single, double LT, or heart–lung transplant at Toronto General Hospital, Toronto, Ontario, Canada, between June 01, 2006, and June 30, 2009, using Electronic Health Records and Organ Transplant Tracking Record. The study period was selected based on a pre-existing database containing LT recipients between 2006 and 2009. Recipients who received re-transplantation within the study period were excluded along with those who died during their post-LT acute hospital stay. The following data were extracted: age at the time of transplant, sex, primary pulmonary diagnosis, pre-transplant functional exercise capacity (measured by the most recent six-minute walk test (6MWT) prior to transplant), most recent Canadian listing urgency status at the time of transplantation, BMI, transplantation from mechanical ventilation, pre- and post-transplant ICU LOS, post-transplant hospital LOS, total hospital LOS, type of transplant, waitlist time, participation in pre-transplant outpatient rehabilitation, and recipients’ discharge destination. Canadian listing priority is based on a subjective determination of illness severity and disease trajectory, rather than a numerical scoring system such as the Lung Allocation Score. Discharge destinations were categorized as home—recipient’s private dwelling within the community with or without Community Care Access Centre (home care) services; inpatient rehabilitation at St. John’s Rehab Program of Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (5); or other medical facility—community hospital closer to patient’s home, nursing home, long-term care, etc. St. John’s Rehab Program of Sunnybrook Health Sciences Centre has a dedicated inpatient rehabilitation program for solid organ transplant recipients. Criteria for admission to this specialized program are as follows: (i) medically stable with no significant fluctuations in medical status within 72 h; (ii) motivated to participate in rehabilitation, has active rehabilitation goals, and is able to participate in two sessions of active rehabilitation therapy 5–7 d a week; (iii) able to sit unsupported for a minimum of 30 min; (iv) cognitive abilities and state of mental health support participation in active rehabilitation; and (v) nonventilated breathing. Special needs such as IV ther-
582
apy, oxygen therapy, tracheotomy, intermitted tube feeds, or ostomy are considered on a case-bycase basis. The standard practice at Toronto General Hospital is for patients to participate in an outpatient rehabilitation program up to three months post-transplant. A chart abstraction instrument was created and assessed for inter-rater reliability among four investigators (MT, NJ, SC, and RB). Two investigators reviewed each chart and extracted the data independently, and the data were entered by a fifth investigator (JLSH). Inconsistencies between the data sets and outliers were verified by confirming with the charts and corrected prior to data analysis. To address the first and second objectives, statistical analyses were performed using Statistical Package for the Social Sciences software (SPSS; version 20; IBM, Armonk, NY, USA). Continuous data (e.g., age, LOS, 6MWD) were first tested for normality using the Shapiro–Wilks test. Descriptive statistics were expressed as frequency and percentage, mean and standard deviation (SD, normally distributed), or median and interquartile range (IQR, non-normally distributed). For normally distributed variables, chi-square (v2) analysis was used to compare the factors between LT recipients discharged home and inpatient rehabilitation; those discharged to other medical facilities were excluded from comparative analysis due to the small sample size. Mann–Whitney U-test was used to compare the two groups on non-normally distributed, continuous variables. Independent samples t-test was used to test for differences for normally distributed variables. To address the third objective, statistical analyses were performed with R version 3.0.2 (open source statistical software). A multivariable logistic regression analysis was conducted. The variables were selected a priori based on the literature and tested for collinearity. There was significant collinearity between age and diagnosis, as well as total LOS and ICU LOS (preand post-transplant), and thus they were analyzed in separate models. The model with the best predictive value is presented in Table 2. A p-value of ≤0.05 was considered significant for all analyses. Results Sample characteristics
Within the study period, 274 LT recipients were identified. Eleven recipients who received re-transplantation, one recipient who was less than 18 yr old, and 19 who died during their post-LT acute hospital stay were excluded from the analysis. A total of 243 LT recipients were included in the
Discharge destination after lung transplant analysis. The median age of LT recipients at transplant was 54 yr (IQR = 40–61 yr). The majority of LT recipients were male (59.7%, n = 145). The two most common pre-transplant diagnoses were chronic obstructive pulmonary disease (COPD) (34.7%; n = 84) and interstitial lung disease (ILD) (33%; n = 81), followed by cystic fibrosis (CF) (20.2%; n = 49). The majority of LT recipients received double LT (81%; n = 196), followed by single LT (15%; n = 37) and heart LT (4%; n = 10). The median of the most recent 6MWD prior to transplant was 296 m (IQR = 216–373). Fifteen LT recipients (6%) required mechanical ventilation as a bridge to transplant. The median post-transplant ICU LOS was five d (IQR = 3– 16), and the median total post-transplant acute care hospital LOS was 22 d (IQR = 16–37). Following LT, the majority of recipients were discharged home (81%; n = 197) or to inpatient rehabilitation (17%; n = 42). A small percentage of recipients were discharged to other medical facilities (2%, n = 4). These recipients were excluded from analyses due to the small sample size. Comparison between LT recipients discharged home and inpatient rehabilitation
LT recipients who were discharged home were younger (53 yr, IQR = 38–61) than recipients discharged to inpatient rehabilitation (57 yr, IQR = 50–64, p = 0.043). Individuals with CF and COPD were more likely to be discharged home, whereas those with ILD and PAH were more likely to be discharged to inpatient rehabilitation (p < 0.001) (Table 1). A greater proportion of recipients who required mechanical ventilation as a bridge to transplantation were discharged to inpatient rehabilitation compared to recipients who did not (p < 0.001). Priority status for transplant (at time of transplantation) was also different between home and inpatient rehabilitation groups, with higher urgency status 2 and rapidly deteriorating candidates more likely to require discharge to inpatient rehabilitation (p < 0.001) (Table 1). Patients discharged home had better functional exercise capacity as measured by the most recent 6MWD before transplant than recipients who were discharged to inpatient rehabilitation (302 m, IQR = 223–402 vs. 250 m, IQR = 153–315, p < 0.05) (Table 1). Participation in pre-transplant rehabilitation differed between the two groups (home = 169 (yes) and 28 (no); rehabilitation = 24 (yes) and 18 (no); p < 0.001) (Table 1). The median post-transplant ICU LOS differed between the two groups (home = four d,
IQR = 3–11; rehabilitation = 22 d, IQR = 9–35; p < 0.001). A difference was also found for the median total LOS following LT (home = 20 d, IQR = 15–28; rehabilitation = 56 d, IQR = 43–88; p < 0.001) (Table 1). There was no difference between the rehabilitation group and home group in sex, BMI, waitlist time, or type of transplant (Table 1). Factors predicting discharge destination after lung transplantation
Results from the final model of the multivariable logistic regression analysis are shown in Table 2. Age, the most recent 6MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were the predictors of discharge destination following LT. For every 10 yr increase in age, the odds ratio to be discharged to inpatient rehabilitation was 1.93 (CI 1.26–2.95). For every 100 m increase in 6MWD, the odds ratio to be discharged to inpatient rehabilitation was 0.67 (CI 0.45–0.99). For pre-transplant mechanical ventilation and total hospital LOS (per one d), the odds ratios to be discharged to inpatient rehabilitation were 10.05 (CI 1.87–53.90) and 1.02 (CI 1.01–1.04), respectively. Discussion
The present study is the first to examine the factors affecting discharge destination following LT. Age, most recent 6MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be the significant independent predictors of discharge destination following LT. With growing evidence supporting the suitability of older patients for LT and an aging population, there is an overall upward trend in the number of older LT recipients over the past decade (2, 3, 19). There is evidence supporting age as a strong predictor of discharge destination in the liver transplantation population (6); the results from the present study also show that age is a predictor of discharge destination in the LT population. While previous studies examining the relationship between advancing age and LT outcomes have yielded inconclusive findings, older age is associated with lower aerobic capacity and sarcopenia (atrophy and weakness of the skeletal muscles) resulting in a decreased functional capacity which may impact discharge destination (3, 11). The 6MWT is a valid clinical outcome measure to assess the functional exercise capacity of individuals with advanced lung disease (20). Although previous studies have shown a relationship
583
584 0 (0–0; 1–110) 5 (3–16) 21 (16–37) 22 (16–43)
21 (8.6)/222 (91.4) 0 (0–0; 0–110) 4 (3–11) 19 (15–27) 20 (15–28)
7 (3.5)/190 (96.5)
57 (28.9) 94 (47.7) 46 (23.4) 302 (223–402) 228.5 (111–379) 23 (19–26) 169 (85.8)/28 (14.2)
31 (15.7) 160 (81.2) 6 (3.0)
37 (15.2) 196 (80.7) 10 (4.1) 61 (25.1) 111 (45.7) 71 (29.2) 296 (216–373) 221 (107–380) 23 (20–26) 197 (81)/46 (18.9)
72 (36.5) 48 (24.4) 60 (30.5) 6 (3.0) 11 (5.6)
53 (38–61) 121 (61.4)/76 (38.6)
84 (34.7) 49 (20.2) 81 (33.3) 12 (4.9) 17 (7.0)
54 (40–61) 145 (59.7)/ 98 (40.3)
Home (n = 197)
0 (0–3; 2–35) 22 (9–35) 52 (39–80) 56 (43–88)
13 (31)/29 (69)
4 (9.5) 13 (31.0) 25 (59.5) 250 (153–315) 181 (71–368) 25 (22–27) 24 (57)/18 (43)
6 (14.3) 32 (76.2) 4 (9.8)
9 (21.4) 1 (2.4) 21 (50) 5 (11.9) 6 (14.3)
57 (50–64) 22 (52.4)/20 (47.6)
Inpatient Rehabilitation (n = 42)
42 (11–91) 160 (26–304) 181 (27–386)
0 (0.0) /4 (100.0)
0 4 (100%) 0 297 (242–329) 363.5 (263–789) 17 (13–24) 4 (100)/0 (0)
0 4 (100) 0
3 (75) 0 0 1 (25) 0
54 (45–64) 2 (50)/2 (50)
Other (n = 4)
7 24
Missing
