Risk of At-Home Mortality After Outpatient Surgery

The increasing preference for outpatient surgery over inpatient procedures reflects advancements in medical technology, anesthesia, and postoperative care. Over the past two decades, the number of surgeries performed on an outpatient basis has risen substantially, with healthcare systems seeking to reduce costs and accommodate patient preferences for a faster discharge and more comfortable recovery at home. While most outpatient surgery is safe and associated with lower overall morbidity, the issue of at-home mortality deserves close attention. The period immediately following discharge represents a vulnerable time, and in certain patient populations, seemingly minor complications can lead to significant, even fatal, outcomes.

Although the overall mortality rate at home after outpatient surgery is low, it is not negligible. Data collected from Medicare populations have shown that mortality within the first seven days after outpatient procedures can range from 25 to 50 per 100,000 cases, depending on the setting in which the surgery was performed. For example, among elderly Medicare beneficiaries, outpatient surgeries performed in ASCs had a seven-day mortality rate of 25 per 100,000, while those conducted in physician offices had slightly higher rates around 35 per 100,000. While these figures are low compared to inpatient surgery, they reveal a persistent risk, particularly within the first 30 days following discharge. Furthermore, data shows that mortality tends to cluster within the first 7 to 30 days post-discharge, underscoring the importance of close monitoring during this period.

Patient-specific factors strongly influence the risk of at-home mortality following outpatient surgery. Frailty—characterized by diminished physiological reserve—is among the most powerful predictors. A meta-analysis involving over 1.1 million surgical patients found that frail individuals had a 3.7-fold higher risk of 30-day mortality compared with non-frail patients. In a large retrospective cohort study, frail patients undergoing major noncardiac surgery had a 13.6% one-year mortality rate versus 4.8% in non-frail patients, corresponding to a hazard ratio of 2.23. Even in lower-risk outpatient procedures, frailty significantly worsens outcomes: very frail patients experienced over 10% 30-day mortality after low-stress procedures and nearly 30% mortality at 180 days. Comorbidity burden further compounds these risks; for example, higher Charlson Comorbidity Index scores were associated with increased mortality and inability to return home postoperatively. Advanced age, cognitive impairment, and limited social support also correlate with poorer outcomes and delayed recognition of complications. Collectively, these data emphasize that frailty and comorbidity drive vulnerability, even in procedures deemed low risk, underscoring the importance of robust preoperative screening and individualized perioperative planning.

To reduce the risk of at-home mortality after outpatient surgery, several strategies can be implemented. Careful patient selection is paramount; not all patients are ideal candidates for outpatient procedures, especially those with significant frailty or poorly controlled chronic illnesses. Pre-habilitation programs, which focus on improving physical and medical fitness before surgery, have shown promise in lowering complication rates. Additionally, closer monitoring of patients who experience minor complications before discharge could help identify those who need more intensive follow-up. Finally, improved postoperative care protocols—including patient education, remote monitoring tools, and structured check-ins—may provide the safety net necessary to prevent avoidable deaths after discharge.

While outpatient surgery is a cornerstone of modern surgical care and is generally associated with favorable outcomes, the rare occurrence of at-home mortality remains a serious concern. Recognizing the risk factors that contribute to such outcomes—frailty, predischarge complications, and insufficient post-discharge support—can help healthcare providers better identify vulnerable patients and design interventions to protect them during this critical recovery period.

References

1. Madsen HJ, Henderson WG, Dyas AR, Bronsert MR, Colborn KL, Lambert-Kerzner A, Meguid RA. Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations. World J Surg. 2023 Mar;47(3):627-639. doi: 10.1007/s00268-022-06819-z.
2. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg. 2004 Jan;139(1):67-72. doi: 10.1001/archsurg.139.1.67.
3. Roshanov PS, Chan MTV, Borges FK, et al. One-year Outcomes after Discharge from Noncardiac Surgery and Association between Predischarge Complications and Death after Discharge: Analysis of the VISION Prospective Cohort Study. Anesthesiology. 2024 Jan 1;140(1):8-24. doi: 10.1097/ALN.0000000000004763.
4. Rothenberg KA, Stern JR, George EL, Trickey AW, Morris AM, Hall DE, Johanning JM, Hawn MT, Arya S. Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA Netw Open. 2019 May 3;2(5):e194330. doi: 10.1001/jamanetworkopen.2019.4330.
5. Sun X, Shen Y, Ji M, Feng S, Gao Y, Yang J, Shen J. Frailty is an independent risk factor of one-year mortality after elective orthopedic surgery: a prospective cohort study. Aging (Albany NY). 2021 Feb 26;13(5):7190-7198. doi: 10.18632/aging.202576.