Study shows geriatric risk factors associated with inability to return home after surgery

Older adults have a different physiology and unique set of needs that may make them more vulnerable to complications following a surgical procedure. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot Project has, for the first time, identified four factors in older patients that are associated with an inability to return home after an operation. The NSQIP Geriatric Surgery Pilot Project is unique in that it is the only specifically defined data set focused on outcomes for older surgical patients.

In presenting study results at the ACS Quality and Safety Conference 2019, concluding today in Washington, DC, researchers reported on geriatric-specific conditions among Geriatric Pilot Project patients that were associated with not living at home 30 days after surgery. This information can help surgeons advise patients about the possible effects of a surgical procedure on their lifestyle as well as their clinical outcomes before an operation. It also may guide hospital quality improvement programs to address pre- and postoperative conditions that may keep elderly surgical patients from returning home soon afterward.

When surgeons speak with older patients about the decision to operate, we discuss complication rates and the risk of mortality. We don't usually talk about whether they will have the independence they had beforehand. In this study, we looked at the NSQIP data set to find factors that influence whether patients are living at home or require support for their functional needs in some kind of facility, such as a nursing home, 30 days after surgery. This information should help us make better preoperative decisions with our patients by allowing us to tell them about the impact a surgical procedure will have on their way of life."

Study coauthor Ronnie Rosenthal, MD, FACS, co-principal investigator of the ACS-led Coalition for Quality in Geriatric Surgery (CQGS) and professor of surgery and geriatrics, Yale University School of Medicine, New Haven, CT.

The NSQIP Geriatric Surgery Pilot Project was created in 2014 to measure and improve the quality of surgical care for older Americans. The project measures preoperative variables and outcome measures that specifically target elderly patients, reflect the quality of their surgical care, and identify interventions that may improve their treatment and well-being.

"Hospitals may implement protocols that improve patient function or prevent postoperative problems that make it less likely for a patient to return home," said study co-author Lindsey Zhang, MD, MS, John A. Hartford Foundation James C. Thompson Clinical Scholar in Residence at ACS, and a general surgery resident at the University of Chicago Medical Center.

The researchers looked at 3,696 patients in the NSQIP Geriatric Surgery Pilot registry who had inpatient procedures between 2015 and 2017 and whose living location 30 days after surgery was known. Eighteen percent of these patients were still living in a care facility 30 days after surgical treatment. The four characteristics identified among these older patients were: a history of a fall within the past year, preoperative malnutrition as defined by more than 10 percent of unintentional weight loss, postoperative delirium, or a new or worsening pressure ulcer after surgery.

"This information empowers physicians to have a conversation with their older surgical patients about the possibility of a stay in an extended care facility, depending on patient characteristics and the nature of the operation they are about to undergo," Dr. Zhang said.

Because this study shows geriatric risk factors that appear to be associated with an extended stay in a care facility, its results may lead to quality improvement initiatives in a hospital. "Should we consider nutrition programs for patients with malnutrition or create programs to improve function for patients who have had a fall? Do we implement protocols in the postop period to prevent delirium and pressure ulcers? Will these steps lead to more patients going home after surgery? We can't say for sure, but these results provide strong evidence to say it's worth the effort for a hospital to address these issues," Dr. Zhang said.

On July 19, the ACS introduced the Geriatric Surgery Verification (GSV) Program by releasing the GSV standards for geriatric surgical care for hospitals to review prior to enrolling in this new surgical quality improvement program in late October. These standards address many key factors in geriatric surgery, including those that may delay an older patient's return home postoperatively.

With support from the John A. Hartford Foundation, the ACS led a coalition of more than 50 stakeholder organizations to create these care standards. Information from the Geriatric Surgery Pilot Project was also instrumental in their development and helped to establish a care framework for any size hospital to utilize in improving the quality of care provided to older surgical patients. Additionally, the new GSV Program aims to promote evidence-based practices, emphasize the importance of shared decision making, and capitalize on interdisciplinary, team-based medicine.

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