NEW YORK – The American College of Surgeons’ National Surgical Improvement Program Geriatric Surgery Pilot Project, which was initiated in 2014, is beginning to bear fruit.
Institutions participating in the project are generating data on geriatric-specific factors such as cognition and mobility that have been shown to add to standard risks associated with surgery in older adults.
“Before you operate at all, there is a decision, and often surgeons use this framework when deciding whether or not to operate: There is an isolated surgical problem, and I think we can fix that problem,” Julia R. Berian, MD, said at the ACS Quality and Safety Conference. “This fails to really incorporate the context of these older, complicated surgical patients.”
“We are facing a silver tsunami. The population is aging,” Emily Finlayson, MD, FACS, said during a separate presentation at the conference. “People are coming to us to decide, A, if they should have surgery, and B, how best to prepare for surgery.”
“As we know, from mounting evidence, surgical outcomes in frail older adults are pretty abysmal.” In addition to the physiologic vulnerabilities, “there is a lot of social isolation, depression, and anxiety that is underdiagnosed in this population,” Dr. Finlayson said. “In light of these incredibly high risks, we need to approach decision making in a slightly different way than we do with, say, a 40-year-old patient.”
Use data to guide interventions
The ACS NSQIP and the ACS Geriatric Task Force created the ACS NSQIP Geriatric Surgery Pilot Project in part to determine if including geriatric-specific preoperative variables and outcome measures in the NSQIP database would improve postoperative outcomes. Since its launch in January 2014, more than 30 hospitals have contributed data from over 30,000 surgical cases involving patients 65 years and older. The vast majority of cases involve orthopedic surgery or general surgery, with total hip and total knee arthroplasty, colectomy, spine surgery, and hip fracture procedures leading the list.
Cognition, function, mobility, and goals/decision making are the four main project domains. “The event rate for postoperative delirium overall was 12%; the functional decline was quite high at 43%; and the need for postoperative mobility aid was 30%,” said Dr. Berian, a fourth-year general surgery resident at the University of Chicago and an ACS Clinical Scholar, when presenting initial 3-year results.
“What we have learned from this experience is that these geriatric-specific risk factors do contribute to risk adjustment for traditional morbidity and mortality outcomes. In other words, we think they are very important to collect,” Dr. Berian said.
Cognitive impairment was associated only with prolonged ventilation, whereas surrogate consent for surgery correlated with any morbidity, reintubation, pneumonia, and more. Use of a mobility aid before surgery correlated with increased risk for a UTI, surgical site infection, sepsis, and other morbidities. A history of falls within the previous year was associated with higher risk of cardiac complications and mortality. Functional status, origin from home before surgery, and use of preoperative palliative care were not contributors to risk.
A second objective of the project is to create a platform for introducing interventions to improve outcomes in this population. Future plans include further validation of the pilot data and incorporation of the results into a geriatric-specific quality program.
Focus on potential solutions
Addressing a wide range of preoperative considerations in older adults may seem daunting, but “there are simple, low-tech things you can do,” said Dr. Finlayson, director of the University of California San Francisco Center for Surgery in Older Adults. Strategies include reviewing medications, providing adequate hydration “so they don’t come in as dry as a potato chip,” and removing earwax. “You might think they’re confused but they really cannot hear.”
Whenever possible, address the core vulnerabilities that put an older patient at higher risk, Dr. Finlayson said. Comorbidity, polypharmacy, incontinence, social isolation, depression and anxiety, as well as deficits in function, nutrition, and mobility can contribute.
Cognition is also critical. If you think an older patient is at risk of postoperative delirium, involve the family, Dr. Finlayson recommended. “We know if family members are at the bedside, the patient is less likely to get confused.” Clinicians at UCSF found this “very helpful” and even give families a sign-up sheet to assign shifts in the hospital.
“If you don’t think delirium is an important outcome to begin tracking in our registries, I want to point out that there are serious consequences for postop delirium,” Dr. Berian said. Delirium alone in surgical patients doubles the increased risk of prolonged length of stay, 1.5 times the risk for institutional discharge, and 2.3 times the risk for 30-day readmission (
Take a team approach
Session moderator David A. Hoyt, MD, FACS, executive director of the American College of Surgeons, asked Dr. Finlayson how she convinced her colleagues to participate in the program at UCSF.
“We haven’t had any problems with buy-in in terms of recognizing the need,” she replied. “The challenge is a lot of surgeons feel like they don’t have the expertise or the time to slow down and learn how to do these assessments and optimization strategies.” She suggested involving geriatricians and other providers when possible. “You have to be very creative within your own system in terms of what kind of team you are going to put together.”
Elicit patient goals
Perhaps most importantly, you really need to individualize your approach, Dr. Finlayson said. Take the time to talk to these patients. “This isn’t just don’t smoke, lose weight, diet and exercise. It’s eliciting patient goals and tailoring an assessment of geriatric vulnerability,” she added. “It’s not one size fits all. It’s not just about fitness for surgery; it’s about what they want for the rest of their lives.”
Patient-driven goals are important, Dr. Berian said, because “older adults may prioritize quality of life over quantity of life.” She also noted that surgery could cure their disease, prolong life, and/or provide symptom relief, or it could cause loss of function and independence, delirium, cognitive loss, and/or premature death. “There was an interesting study … looking at outcomes that could be considered worse than death,” Dr. Berian said (). Bowel and bladder incontinence, being confused all the time, and relying on a feeding tube to live were among the outcomes the researchers examined.
Dr. Finlayson highlighted a high-touch, resource-intensive, and successful intervention in older patients in the United Kingdom (). “The reduction in morbidity was incredibly dramatic.” The study shows if you truly have the resources to address these geriatric syndromes, you can really improve care in this population.
Dr. Berian had no relevant financial disclosures. Dr. Finlayson is a founding shareholder of Ooney, Inc.