Suprapubic catheter (SPC) placement is common in nursing home residents, yet surgical outcomes in this population are largely unknown. In particular, outcomes that go beyond 30-day complications and encompass important longer-term mortality, function, and cognition are lacking. To address this knowledge gap, we designed a retrospective cohort study to evaluate long-term functional and cognitive outcomes in nursing home residents following SPC placement. We hypothesized that we would see marked declines in function and cognition in this cohort, even after this seemingly “minor” procedure.

The population of interest was long-term nursing home residents who underwent SPC placement from 2014-2016 in the United States. SPC placement procedures were identified in Medicare Inpatient, Outpatient, and Carrier files via corresponding International Classification of Diseases Ninth Revision (ICD-9), Tenth Revision (ICD-10), and Current Procedural Terminology (CPT) procedure codes. Nursing home residents were identified using the Minimum Data Set 3.0 (MDS) for Nursing Home Residents. Outcomes of interest included functional and cognitive status, which were measured in the MDS by the MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores, respectively. We also measured 1-year mortality using the Master Beneficiary Summary File. Trajectories of MDS-ADL and BIMS scores were visualized with mixed-effects spline models in patients with data available to 1 year after SPC placement. Multivariate Generalized Estimating Equations (GEEs) were also used to assess worsening MDS-ADL and BIMS at 12 months postoperatively, and were adjusted by age, gender, race, Charlson Comorbidity Index, frailty, baseline MDS-ADL and BIMS scores, and procedure date. Only residents who had complete data 1 year postoperatively were included.

From 2014-2016, 9,647 nursing home residents underwent SPC placement in the United States. Mean age was 80.9 years (standard deviation [SD] 8.1), and the cohort was predominantly male (77.3%), white (84.7%), and had a mean Charlson Comorbidity score of 5.5 (SD 3.6). At 1 year after SPC placement, 61.1% of residents had worsened MDS-ADL score and 37.6% had a decline in BIMS score. One-year mortality was 37.6%. Overall, residents demonstrated a stable preoperative MDS-ADL trajectory, followed by a sharp decline in MDS-ADL scores at the time of SPC placement (time 0 in Fig. 1), which never recovered to preoperative MDS-ADL scores up to 12 months after surgery; BIMS scores steadily declined up to 1 year after surgery, despite SPC placement. On multivariate regression, worsening MDS-ADL score was significantly associated with moderate-to-severe frailty (relative risk [RR] 1.10, 95% confidence interval [CI] 1.04-1.17) versus no frailty, Charlson Comorbidity scores >8 (RR 1.22, 95% CI 1.15-1.29) versus scores of 0-2, and severe baseline cognitive impairment on BIMS (RR 1.14, 95% CI 1.09-1.19) versus intact cognition. Worsening BIMS score was associated with moderate-to-severe frailty (RR 1.19, 95% CI 1.07-1.32) versus no frailty, Charlson Comorbidity scores >8 (RR 1.32, 95% CI 1.18-1.46) versus scores of 0-2, and baseline MDS-ADL score of 20-28 (RR 1.13, 95% CI 1.03-1.24) versus baseline scores from 0-11.

In this study, over one-third of nursing home residents died within a year of SPC placement. Residents had sharper rates of functional decline postoperatively and never recovered to baseline functional status. Decline in cognitive status was not clearly associated with SPC placement, which suggests either the natural course of a highly vulnerable population or limitations of BIMS score measurements.

SPC placement is associated with high mortality, increased functional decline, and continued cognitive decline up to 1 year after surgery. These findings emphasize that even a relatively “minor” procedure like SPC placement should be considered with caution in this vulnerable population.