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Cheng H, Ling Y, Li Q, Li X, Tang Y, Guo J, Li J, Wang Z, Ming W, Lyu J. Association between modified frailty index and postoperative delirium in patients after cardiac surgery: A cohort study of 2080 older adults. CNS Neurosci Ther 2024; 30:e14762. [PMID: 38924691 PMCID: PMC11199331 DOI: 10.1111/cns.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024] Open
Abstract
AIM To evaluate the association between frailty and postoperative delirium (POD) in elderly cardiac surgery patients. METHODS A retrospective study was conducted of older patients admitted to the intensive care unit after cardiac surgery at a tertiary academic medical center in Boston from 2008 to 2019. Frailty was measured using the Modified Frailty Index (MFI), which categorized patients into frail (MFI ≥3) and non-frail (MFI = 0-2) groups. Delirium was identified using the confusion assessment method for the intensive care unit and nursing notes. Logistic regression models were used to examine the association between frailty and POD, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS Of the 2080 patients included (median age approximately 74 years, 30.9% female), 614 were frail and 1466 were non-frail. The incidence of delirium was significantly higher in the frail group (29.2% vs. 16.4%, p < 0.05). After adjustment for age, sex, race, marital status, Acute Physiology Score III (APSIII), sequential organ failure assessment (SOFA), albumin, creatinine, hemoglobin, white blood cell count, type of surgery, alcohol use, smoking, cerebrovascular disease, use of benzodiazepines, and mechanical ventilation, multivariate logistic regression indicated a significantly increased risk of delirium in frail patients (adjusted OR: 1.61, 95% CI: 1.23-2.10, p < 0.001, E-value: 1.85). CONCLUSIONS Frailty is an independent risk factor for POD in older patients after cardiac surgery. Further research should focus on frailty assessment and tailored interventions to improve outcomes.
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Affiliation(s)
- Hongtao Cheng
- School of NursingJinan UniversityGuangzhouChina
- Department of Clinical ResearchThe First Affiliated Hospital of Jinan UniversityGuangzhouChina
| | - Yitong Ling
- Department of NeurologyThe First Affiliated Hospital of Jinan UniversityGuangzhouChina
| | - Qiugui Li
- School of NursingJinan UniversityGuangzhouChina
| | - Xinya Li
- School of NursingJinan UniversityGuangzhouChina
| | | | - Jiayu Guo
- School of Public HealthShanxi University of Chinese MedicineXianyangChina
| | - Jing Li
- School of Public HealthShanxi University of Chinese MedicineXianyangChina
| | - Zichen Wang
- Department of Clinical ResearchThe First Affiliated Hospital of Jinan UniversityGuangzhouChina
| | - Wai‐kit Ming
- Department of Infectious Diseases and Public HealthCity University of Hong KongHong KongChina
| | - Jun Lyu
- Department of Clinical ResearchThe First Affiliated Hospital of Jinan UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine InformatizationGuangzhouChina
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Nakatsuka K, Ono R, Murata S, Akisue T, Fukuda H. Claims-based Frailty Index in Japanese Older Adults: A Cohort Study Using LIFE Study Data. J Epidemiol 2024; 34:112-118. [PMID: 36967119 PMCID: PMC10853043 DOI: 10.2188/jea.je20220310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/21/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND We aimed to assess whether the United States-developed Claims-based Frailty Index (CFI) can be implemented in Japanese older adults using claims data. METHODS We used the monthly claims data and certification of long-term care (LTC) insurance data of residents from 12 municipalities from April 2014 to March 2019. The 12 months from first recording was defined as the "baseline period," and the time thereafter as the "follow-up period". Participants aged ≥65 years were included, and those with no certified LTC insurance or who died at baseline were excluded. New certification of LTC insurance and all-cause mortality during the follow-up period were defined as outcome events. CFI categorization consisted of three steps including: 1) using 12 months deficit-accumulation approach that assigned different weights to each of the 52 items; 2) the accumulated score to derive the CFI; and 3) categorizing the CFI as "robust" (<0.15), "prefrail" (0.15-0.24), and "frail" (≥0.25). Kaplan-Meier survival curves and Cox proportional hazard models were used to determine the association between CFI and outcomes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. RESULTS There were 519,941 participants in total. After adjusting for covariates, the severe CFI category had a high risk of certification of LTC insurance (prefrail: HR 1.33; 95% CI, 1.27-1.39 and frail: HR 1.60; 95% CI, 1.53-1.68) and all-cause mortality (prefrail: HR 1.44; 95% CI, 1.29-1.60 and frail: HR 1.84; 95% CI, 1.66-2.05). CONCLUSION This study suggests that CFI can be implemented in Japanese claims data to predict the certification of LTC insurance and mortality.
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Affiliation(s)
- Kiyomasa Nakatsuka
- Kobe University Graduate School of Health Sciences, Kobe, Japan
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Rei Ono
- Kobe University Graduate School of Health Sciences, Kobe, Japan
- Department of Physical Activity Research, National Institutes of Biomedical Innovation, Health and Nutrition, National Institute of Health and Nutrition, Tokyo, Japan
| | - Shunsuke Murata
- Kobe University Graduate School of Health Sciences, Kobe, Japan
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | | | - Haruhisa Fukuda
- Kyushu University Graduate School of Medical Sciences, Department of Health Care Administration and Management, Fukuoka, Japan
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Zogg CK, Falvey JR, Kodadek LM, Staudenmayer KL, Davis KA. The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients. J Trauma Acute Care Surg 2024; 96:400-408. [PMID: 37962136 PMCID: PMC10922165 DOI: 10.1097/ta.0000000000004191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND When presenting for emergency general surgery (EGS) care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ("geriatric vulnerability") and the social determinants of health unique to the places in which they live ("neighborhood vulnerability"). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults. METHODS Older adults, 65 years or older, hospitalized with an AAST-defined EGS condition were identified in the 2016 to 2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g., access to transportation). RESULTS A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six times greater risk of death (30-day risk-adjusted hazards ratio [HR], 6.32; 95% confidence interval [CI], 4.49-8.89). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to 15 times greater risk of death (30-day risk-adjusted HR, 15.12; 95% CI, 12.57-18.19). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day HRs for mortality of 11.53 (95% CI, 4.51-29.44) versus 40.67 (95% CI, 22.73-72.78). Similar patterns were seen for death within 365 days. CONCLUSION Both geriatric and neighborhood vulnerability have been shown to affect prehospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Timan TJ, Ekerstad N, Karlsson O, Sernert N, Prytz M. One-year mortality rates after standardized management for emergency laparotomy: results from the Swedish SMASH study. BJS Open 2024; 8:zrad133. [PMID: 38284401 PMCID: PMC10823779 DOI: 10.1093/bjsopen/zrad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/21/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Patients who require an emergency laparotomy suffer from high mortality and morbidity rates. Studies have shown that the standardization of perioperative management reduces complications in the short term. The aim of the present study was to report long-term mortality rates for the SMASH (Standardized perioperative Management of patients operated with acute Abdominal Surgery in a High-risk and emergency setting) study, as well as short- and long-term outcomes for different age groups within the SMASH study. METHODS A prospective intervention study was introduced in 2018, with the aim of investigating the introduction of a standardized protocol for emergency laparotomy. For 42 months, intervention patients were managed according to the protocol and outcomes were then compared with those of historical controls. RESULTS A total of 1344 unique patients were included (681 in the intervention group and 663 in the control group). The 90-day mortality rate was 14.1 per cent in the intervention group and 20.8 per cent in the control group (P = 0.002) and the 1-year mortality rate in adjusted analyses was 19.7 and 27.8 per cent respectively (P =< 0.001). An age-related subgroup analysis showed that the oldest patients (76 years and older, 260 in the intervention group and 240 in the control group) had a 1-year mortality rate of 29.6 and 43.8 per cent respectively (P = 0.004) and a mean duration of hospital stay of 9.9 and 11.6 days respectively (P = 0.027). Among older adults (61-75 years), the mean duration of hospital stay was 11.7 days in the intervention group compared with 15.1 days in the control group (P = 0.009) and the mean duration of ICU care was reduced to 4.49 days compared with 7.29 days (P = 0.046). CONCLUSION The standardized protocol associated with an emergency laparotomy appears to be beneficial, even in the long term. For elderly patients, it appears to reduce mortality rates and the durations of hospital stay and ICU care.
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Affiliation(s)
- Terje Jansson Timan
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Anaesthesiology and Intensive Care, NU Hospital Group, Trollhättan, Sweden
| | - Niklas Ekerstad
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Ove Karlsson
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ninni Sernert
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
| | - Mattias Prytz
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Surgery, NU Hospital Group, Trollhättan, Sweden
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Greenberg B, Jiang S, Nadler A. Postoperative protocols for older adults undergoing emergency surgery: a scoping review. Can J Surg 2024; 67:E149-E157. [PMID: 38575179 PMCID: PMC11001382 DOI: 10.1503/cjs.011323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND As the population of older adults expands, it is becoming increasingly crucial to develop perioperative protocols to meet their physiologic, functional, and cognitive demands after emergency surgery. We sought to identify protocols that improve the disposition, length of stay, and overall health outcomes of older adults undergoing emergency intracavitary, noncardiac surgery. METHODS Embase, Cochrane, and MEDLINE databases were searched, and results were deduplicated and uploaded to Covidence. We reviewed studies for postoperative interventions that reduced delirium, maintained functional status, and reduced length of stay in older patients undergoing emergency surgery. We included studies involving patients aged 65 years and older undergoing emergency intracavitary, noncardiac surgeries. Abstracts and full texts were reviewed by 2 reviewers. Data were extracted on the postoperative interventions used and the resulting patient outcomes. RESULTS We included 6 studies, which involved patients undergoing emergency general, urology, and vascular surgery. Interventions included a multidisciplinary approach, early involvement of a geriatrician or hospitalist, targeted geriatric-led ward rounds, unique postoperative order sets, and volunteer-driven activities. Standard care included early removal of lines, early mobility, optimal hydration, and medication review. These interventions were associated with decreased length of stay, decreased postoperative complications, and increased likelihood of disposition to home and previous functional status. Frailty was correlated with worse outcomes. CONCLUSION Through multidisciplinary interventions, a successful postoperative protocol for older patients undergoing emergency surgery is helpful for improving patient outcomes. The implications of these findings will help guide our own quality-improvement initiative to improve these outcomes in this patient population at our institution.
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Affiliation(s)
- Brianna Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| | - Stephanie Jiang
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| | - Ashlie Nadler
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
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Schaefer G, Regier D, Stout C. Palliative Emergency General Surgery. Surg Clin North Am 2023; 103:1283-1296. [PMID: 37838468 DOI: 10.1016/j.suc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Acute care surgeons encounter patients experiencing surgical emergencies related to advanced malignancy, catastrophic vascular events, or associated with multisystem organ failure. The acute nature is a factor in establishing a relationship between surgeon, patient, and family. Surgeons must use effective communication skills, empathy, and a knowledge of legal and ethical foundations. Training in palliative care principles is limited in many medical school and residency curricula. We offer examples of clinical situations facing acute care surgeons and discuss evidence-based recommendations to facilitate successful treatment and outcomes.
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Affiliation(s)
- Gregory Schaefer
- Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Surgical Critical Care, J.W. Ruby Memorial Hospital, West Virginia University Medicine, West Virginia University, Morgantown, WV, USA; Division of Military Medicine, J.W. Ruby Memorial Hospital, West Virginia University Medicine, West Virginia University, Morgantown, WV, USA; Department of Surgery, West Virginia University, Morgantown, WV, USA.
| | - Daniel Regier
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Conley Stout
- Department of Surgery, West Virginia University, Morgantown, WV, USA
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Rosen CB, Roberts SE, Wirtalla CJ, Keele LJ, Kaufman EJ, Halpern SD, Reilly PM, Neuman MD, Kelz RR. The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis. Ann Surg 2023; 278:e855-e862. [PMID: 37212397 PMCID: PMC10524950 DOI: 10.1097/sla.0000000000005901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions. BACKGROUND EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity. METHODS Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions. RESULTS Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients. CONCLUSIONS The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.
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Affiliation(s)
- Claire B Rosen
- Department of Surgery, Hospital of the University of Pennsylvania
| | | | - Chris J Wirtalla
- Department of Medicine, Hospital of the University of Pennsylvania
| | - Luke J Keele
- Department of Surgery, Hospital of the University of Pennsylvania
| | | | - Scott D Halpern
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Patrick M Reilly
- Department of Surgery, Hospital of the University of Pennsylvania
| | - Mark D Neuman
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient. World J Surg 2023; 47:1881-1898. [PMID: 37277506 PMCID: PMC10241556 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA 91101 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen’s Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
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Zogg CK, Cooper Z, Peduzzi P, Falvey JR, Tinetti ME, Lichtman JH. Beyond In-hospital Mortality: Use of Postdischarge Quality-Metrics Provides a More Complete Picture of Older Adult Trauma Care. Ann Surg 2023; 278:e314-e330. [PMID: 36111845 PMCID: PMC10014495 DOI: 10.1097/sla.0000000000005707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the distributions of and extent of variability among 3 new sets of postdischarge quality-metrics measured within 30/90/365 days designed to better account for the unique health needs of older trauma patients: mortality (expansion of the current in-hospital standard), readmission (marker of health-system performance and care coordination), and patients' average number of healthy days at home (marker of patient functional status). BACKGROUND Traumatic injuries are a leading cause of death and loss of independence for the increasing number of older adults living in the United States. Ongoing efforts seek to expand quality evaluation for this population. METHODS Using 100% Medicare claims, we calculated hospital-specific reliability-adjusted postdischarge quality-metrics for older adults aged 65 years or older admitted with a primary diagnosis of trauma, older adults with hip fracture, and older adults with severe traumatic brain injury. Distributions for each quality-metric within each population were assessed and compared with results for in-hospital mortality, the current benchmarking standard. RESULTS A total of 785,867 index admissions (305,186 hip fracture and 92,331 severe traumatic brain injury) from 3692 hospitals were included. Within each population, use of postdischarge quality-metrics yielded a broader range of outcomes compared with reliance on in-hospital mortality alone. None of the postdischarge quality-metrics consistently correlated with in-hospital mortality, including death within 1 year [ r =0.581 (95% CI, 0.554-0.608)]. Differences in quintile-rank revealed that when accounting for readmissions (8.4%, κ=0.029) and patients' average number of healthy days at home (7.1%, κ=0.020), as many as 1 in 14 hospitals changed from the best/worst performance under in-hospital mortality to the completely opposite quintile rank. CONCLUSIONS The use of new postdischarge quality-metrics provides a more complete picture of older adult trauma care: 1 with greater room for improvement and better reflection of multiple aspects of quality important to the health and recovery of older trauma patients when compared with reliance on quality benchmarking based on in-hospital mortality alone.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham & Women’s Hospital, Boston, MA
| | - Peter Peduzzi
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Mary E. Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
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10
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Rosen CB, Roberts SE, Syvyk S, Finn C, Tong J, Wirtalla C, Spinks H, Kelz RR. A Novel Mobile App to Identify Patients With Multimorbidity in the Emergency Setting: Development of an App and Feasibility Trial. JMIR Form Res 2023; 7:e42970. [PMID: 37440310 PMCID: PMC10375392 DOI: 10.2196/42970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/14/2023] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Multimorbidity is associated with an increased risk of poor surgical outcomes among older adults; however, identifying multimorbidity in the clinical setting can be a challenge. OBJECTIVE We created the Multimorbid Patient Identifier App (MMApp) to easily identify patients with multimorbidity identified by the presence of a Qualifying Comorbidity Set and tested its feasibility for use in future clinical research, validation, and eventually to guide clinical decision-making. METHODS We adapted the Qualifying Comorbidity Sets' claims-based definition of multimorbidity for clinical use through a modified Delphi approach and developed MMApp. A total of 10 residents input 5 hypothetical emergency general surgery patient scenarios, common among older adults, into the MMApp and examined MMApp test characteristics for a total of 50 trials. For MMApp, comorbidities selected for each scenario were recorded, along with the number of comorbidities correctly chosen, incorrectly chosen, and missed for each scenario. The sensitivity and specificity of identifying a patient as multimorbid using MMApp were calculated using composite data from all scenarios. To assess model feasibility, we compared the mean task completion by scenario to that of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS-NSQIP-SRC) using paired t tests. Usability and satisfaction with MMApp were assessed using an 18-item questionnaire administered immediately after completing all 5 scenarios. RESULTS There was no significant difference in the task completion time between the MMApp and the ACS-NSQIP-SRC for scenarios A (86.3 seconds vs 74.3 seconds, P=.85) or C (58.4 seconds vs 68.9 seconds,P=.064), MMapp took less time for scenarios B (76.1 seconds vs 87.4 seconds, P=.03) and E (20.7 seconds vs 73 seconds, P<.001), and more time for scenario D (78.8 seconds vs 58.5 seconds, P=.02). The MMApp identified multimorbidity with 96.7% (29/30) sensitivity and 95% (19/20) specificity. User feedback was positive regarding MMApp's usability, efficiency, and usefulness. CONCLUSIONS The MMApp identified multimorbidity with high sensitivity and specificity and did not require significantly more time to complete than a commonly used web-based risk-stratification tool for most scenarios. Mean user times were well under 2 minutes. Feedback was overall positive from residents regarding the usability and usefulness of this app, even in the emergency general surgery setting. It would be feasible to use MMApp to identify patients with multimorbidity in the emergency general surgery setting for validation, research, and eventual clinical use. This type of mobile app could serve as a template for other research teams to create a tool to easily screen participants for potential enrollment.
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Affiliation(s)
| | | | - Solomiya Syvyk
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Caitlin Finn
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Tong
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | | | - Hunter Spinks
- Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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11
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Deverakonda DL, Kishawi SK, Lapinski MF, Adomshick VJ, Siff JE, Brown LR, Ho VP. What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients. J Surg Res 2023; 284:29-36. [PMID: 36529078 PMCID: PMC9911375 DOI: 10.1016/j.jss.2022.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC). MATERIALS AND METHODS We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations. RESULTS We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations. CONCLUSIONS Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.
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Affiliation(s)
| | - Sami K Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | - Jonathan E Siff
- Department of Emergency Medicine and the Center for Clinical Informatics Research and Education, MetroHealth Medical Center, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
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12
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Barthold LK, Burney CP, Baumann LE, Briggs A. Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience. J Surg Res 2023; 283:640-647. [PMID: 36455417 DOI: 10.1016/j.jss.2022.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. MATERIALS AND METHODS We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. RESULTS Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). CONCLUSIONS At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.
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Affiliation(s)
- Laura K Barthold
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laura E Baumann
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexandra Briggs
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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13
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Ho VP, Bensken WP, Flippin JA, Santry HP, Claridge JA, Towe CW, Koroukian SM. Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions. J Surg Res 2023; 283:224-232. [PMID: 36423470 PMCID: PMC9923717 DOI: 10.1016/j.jss.2022.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Emergency General Surgery (EGS) conditions in older patients constitutes a substantial public health burden due to high morbidity and mortality. We sought to utilize a supervised machine learning method to determine combinations of factors with the greatest influence on long-term survival in older EGS patients. METHODS We identified community dwelling participants admitted for EGS conditions from the Medicare Current Beneficiary Survey linked with claims (1992-2013). We categorized three binary domains of multimorbidity: chronic conditions, functional limitations, and geriatric syndromes (such as vision or hearing impairment, falls, incontinence). We also collected EGS disease type, age, and sex. We created a classification and regression tree (CART) model to identify groups of variables associated with our outcome of interest, three-year survival. We then performed Cox proportional hazards analysis to determine hazard ratios for each group with the lowest risk group as reference. RESULTS We identified 1960 patients (median age 79 [interquartile range [IQR]: 73, 85], 59.5% female). The CART model identified the presence of functional limitations as the primary splitting variable. The lowest risk group were patient aged ≤81 y with biliopancreatic disease and without functional limitations. The highest risk group was men aged ≥75 y with functional limitations (hazard ratio [HR] 11.09 (95% confidence interval [CI] 5.91-20.83)). Notably absent from the CART model were chronic conditions and geriatric syndromes. CONCLUSIONS More than the presence of chronic conditions or geriatric syndromes, functional limitations are an important predictor of long-term survival and must be included in presurgical assessment.
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Affiliation(s)
- Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - J Alford Flippin
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Heena P Santry
- Department of Surgery, Kettering Hospital, Columbus, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
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14
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Streid JL, Lee KC, Bader AM, Jarman MP, Rosenthal RA, Cooper Z, Lindvall C. Shared Decision Making in the Geriatric Surgery Verification Program: Assessing Baseline Performance. J Pain Symptom Manage 2023; 65:510-520.e3. [PMID: 36736861 DOI: 10.1016/j.jpainsymman.2023.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
CONTEXT As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown. OBJECTIVES To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence. METHODS Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes. RESULTS A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00-1.68), undergoing colectomy (OR 2.82; 95% CI 2.15-3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14-2.09]). CONCLUSION Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.
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Affiliation(s)
- Jocelyn L Streid
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine (J.L.S., A.M.B.), Brigham and Women's Hospital, Boston, Massachusetts.
| | - Katherine C Lee
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (K.C.L.), University of California, San Diego, La Jolla, California
| | - Angela M Bader
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine (J.L.S., A.M.B.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Molly P Jarman
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Zara Cooper
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (Z.C.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Division of Palliative Medicine, Department of Medicine (C.L.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L.), Boston, Massachusetts
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15
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Zogg CK, Staudenmayer KL, Kodadek LM, Davis KA. Reconceptualizing high-quality emergency general surgery care: Non-mortality-based quality metrics enable meaningful and consistent assessment. J Trauma Acute Care Surg 2023; 94:68-77. [PMID: 36245079 PMCID: PMC9805506 DOI: 10.1097/ta.0000000000003818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ongoing efforts to promote quality-improvement in emergency general surgery (EGS) have made substantial strides but lack clear definitions of what constitutes "high-quality" EGS care. To address this concern, we developed a novel set of five non-mortality-based quality metrics broadly applicable to the care of all EGS patients and sought to discern whether (1) they can be used to identify groups of best-performing EGS hospitals, (2) results are similar for simple versus complex EGS severity in both adult (18-64 years) and older adult (≥65 years) populations, and (3) best performance is associated with differences in hospital-level factors. METHODS Patients hospitalized with 1-of-16 American Association for the Surgery of Trauma-defined EGS conditions were identified in the 2019 Nationwide Readmissions Database. They were stratified by age/severity into four cohorts: simple adults, complex adults, simple older adults, complex older adults. Within each cohort, risk-adjusted hierarchical models were used to calculate condition-specific risk-standardized quality metrics. K-means cluster analysis identified hospitals with similar performance, and multinomial regression identified predictors of resultant "best/average/worst" EGS care. RESULTS A total of 1,130,496 admissions from 984 hospitals were included (40.6% simple adults, 13.5% complex adults, 39.5% simple older adults, and 6.4% complex older adults). Within each cohort, K-means cluster analysis identified three groups ("best/average/worst"). Cluster assignment was highly conserved with 95.3% of hospitals assigned to the same cluster in each cohort. It was associated with consistently best/average/worst performance across differences in outcomes (5×) and EGS conditions (16×). When examined for associations with hospital-level factors, best-performing hospitals were those with the largest EGS volume, greatest extent of patient frailty, and most complicated underlying patient case-mix. CONCLUSION Use of non-mortality-based quality metrics appears to offer a needed promising means of evaluating high-quality EGS care. The results underscore the importance of accounting for outcomes applicable to all EGS patients when designing quality-improvement initiatives and suggest that, given the consistency of best-performing hospitals, natural EGS centers-of-excellence could exist. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
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16
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Rosen CB, Roberts SE, Wirtalla CJ, Ramadan OI, Keele LJ, Kaufman EJ, Halpern SD, Kelz RR. Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study. J Am Coll Surg 2022; 235:724-735. [PMID: 36250697 PMCID: PMC9583235 DOI: 10.1097/xcs.0000000000000303] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.
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Affiliation(s)
- Claire B Rosen
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Chris J Wirtalla
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
| | - Luke J Keele
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Elinore J Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Scott D Halpern
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
- Department of Medicine, Hospital of the University of Pennsylvania; Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
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17
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Chou WH, Covinsky K, Zhao S, Boscardin WJ, Finlayson E, Suskind AM. Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study. J Am Geriatr Soc 2022; 70:2948-2957. [PMID: 35696283 PMCID: PMC9588579 DOI: 10.1111/jgs.17928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement. METHODS We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models. RESULTS From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores. CONCLUSIONS Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.
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Affiliation(s)
| | - Kenneth Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA
| | - Shoujun Zhao
- Department of Urology, University of California, San Francisco, San Francisco, CA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Anne M. Suskind
- Department of Urology, University of California, San Francisco, San Francisco, CA
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18
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Kołodziejska K, Witowski J, Tylec P, Grochowska A, Przytuła N, Lis M, Pędziwiatr M, Rubinkiewicz M. Radiological Features for Frailty Assessment in Patients Requiring Emergency Laparotomy. J Clin Med 2022; 11:jcm11185365. [PMID: 36143012 PMCID: PMC9505058 DOI: 10.3390/jcm11185365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: As the number of elderly patients requiring surgical intervention rises, it is believed that frailty syndrome has a greater impact on perioperative course than on chronological age. The aim of this study was to evaluate the efficacy of various imaging features for frailty assessment in patients undergoing emergency laparotomy. Methods: The study included all patients that qualified for emergency surgery with preoperative CT scans between 2016 and 2020 in the Second Department of General Surgery. Multiple trauma patients were excluded from the analysis. The modified frailty index and brief geriatric assessment were used in the analysis. CT images were reviewed for the assessment of osteopenia, sarcopenia, sarcopenic obesity, renal volume and abdominal aorta calcification rate. Results: A total of 261 patients were included in the analysis. Multivariate logistic regression identified every next ASA class (OR: 4.161, 95%CI: 1.672–10.355, p = 0.002), intraoperative adverse events (OR: 12.397, 95%CI: 2.166–70.969, p = 0.005) and osteopenia (OR: 4.213, 95%CI: 1.235–14.367, p = 0.022) as a risk factor for 30-day mortality. Our study showed that every next ASA class (OR: 1.952, 95%Cl: 1.171–3.256, p = 0.010) and every point of the BGA score (OR: 1.496, 95%Cl: 1.110–2.016, p = 0.008) are risk factors for major complications. Conclusions: Osteopenia was the best parameter for perioperative mortality risk stratification in patients undergoing emergency surgical intervention. Sarcopenia (measured as psoas muscle area), sarcopenic obesity, aortic calcifications and mean kidney volume do not predict poor outcomes in those patients. None of the radiological markers appeared to be useful for the prediction of perioperative morbidity.
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Affiliation(s)
- Katarzyna Kołodziejska
- Department of Medical Education, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Jan Witowski
- Department of Radiology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Piotr Tylec
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Anna Grochowska
- Department of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Natalia Przytuła
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Maciej Lis
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Mateusz Rubinkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, 31-008 Kraków, Poland
- Correspondence:
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Alkadri J, Aucoin SD, McDonald B, Grubic N, McIsaac DI. Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study. Br J Anaesth 2022; 129:536-543. [PMID: 36031415 DOI: 10.1016/j.bja.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Frailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. METHODS A retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. RESULTS We identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60-0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64-0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. CONCLUSIONS In patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.
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Affiliation(s)
- Jamal Alkadri
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; ICES, Ottawa, ON, Canada.
| | - Sylvie D Aucoin
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bernard McDonald
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Nicholas Grubic
- ICES, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; ICES, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
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20
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Rosen CB, Wirtalla C, Keele LJ, Roberts SE, Kaufman EJ, Holena DN, Halpern SD, Kelz RR. Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities: A Retrospective Observational Study. Med Care 2022; 60:616-622. [PMID: 35640050 PMCID: PMC9262850 DOI: 10.1097/mlr.0000000000001733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients. OBJECTIVE The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery. RESEARCH DESIGN Retrospective observational study using state discharge data. SUBJECTS Medicare beneficiaries who underwent an operation for an emergency general surgery condition in New York, Florida, or Pennsylvania (2012-2013). MEASURES Patients were classified as multimorbid using Qualifying Comorbidity Sets (QCSs). Outcomes included in-hospital mortality, hospital length of stay and discharge status. RESULTS Of 312,160 patients, a large minority (37.4%) were multimorbid. Non-QCS patients did not have a specific combination of comorbidities to satisfy a QCS, but 64.1% of these patients had 3+ comorbid conditions. Multimorbidity was associated with increased in-hospital mortality (10.5% vs. 3.9%, P <0.001), decreased rates of discharge to home (16.2% vs. 37.1%, P <0.001), and longer length of stay (10.4 d±13.5 vs. 6.7 d±9.3, P <0.001) when compared with non-QCS patients. Risks varied between individual QCSs. CONCLUSIONS Multimorbidity, defined by satisfying a specific QCS, is strongly associated with poor outcomes for older patients requiring emergency general surgery in the United States. Variation in risk of in-hospital mortality, discharge status, and length of stay between individual QCSs suggests that multimorbidity does not carry the same prognostic weight as having multiple comorbidities-the specifics of which are important in setting expectations for individual, complex patients.
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Affiliation(s)
- Claire B. Rosen
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Chris Wirtalla
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Luke J. Keele
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Sanford E. Roberts
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Elinore J. Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Daniel N. Holena
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Scott D. Halpern
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Department of Medicine, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
| | - Rachel R. Kelz
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
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21
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Ho VP, Bensken WP, Santry HP, Towe CW, Warner DF, Connors AF, Koroukian SM. Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions. Surgery 2022; 172:446-452. [PMID: 35397953 PMCID: PMC9232899 DOI: 10.1016/j.surg.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions. METHODS We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management. RESULTS Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health. CONCLUSION Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.
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Affiliation(s)
- Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH. https://twitter.com/Wyatt_Bensken
| | - Heena P Santry
- Department of Surgery, Kettering Health, Kettering, OH; NBBJ Design, Columbus, OH. https://twitter.com/heenastat
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, OH
| | - David F Warner
- Department of Sociology, University of Alabama at Birmingham, AL; Center for Family and Demographic Research, Bowling Green State University, OH. https://twitter.com/dwarnersoc
| | - Alfred F Connors
- Department of Medicine, MetroHealth Medical Center, Cleveland, OH
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH. https://twitter.com/KoroukianLab
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22
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Jin Y, Schneeweiss S, Merola D, Lin KJ. Impact of longitudinal data-completeness of electronic health record data on risk score misclassification. J Am Med Inform Assoc 2022; 29:1225-1232. [PMID: 35357470 PMCID: PMC9196679 DOI: 10.1093/jamia/ocac043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/22/2022] [Accepted: 03/11/2022] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Electric health record (EHR) discontinuity, that is, receiving care outside of a given EHR system, can lead to substantial information bias. We aimed to determine whether a previously described EHR-continuity prediction model can reduce the misclassification of 4 commonly used risk scores in pharmacoepidemiology. METHODS The study cohort consists of patients aged ≥ 65 years identified in 2 US EHR systems linked with Medicare claims data from 2007 to 2017. We calculated 4 risk scores, CHAD2DS2-VASc, HAS-BLED, combined comorbidity score (CCS), claims-based frailty index (CFI) based on information recorded in the 365 days before cohort entry, and assessed their misclassification by comparing score values based on EHR data alone versus the linked EHR-claims data. CHAD2DS2-VASc and HAS-BLED were assessed in atrial fibrillation (AF) patients, whereas CCS and CFI were assessed in the general population. RESULTS Our study cohort included 204 014 patients (26 537 with nonvalvular AF) in system 1 and 115 726 patients (15 529 with nonvalvular AF) in system 2. Comparing the low versus high predicted EHR continuity in system 1, the proportion of patients with misclassification of ≥2 categories improved from 55% to 16% for CHAD2DS2-VASc, from 55% to 12% for HAS-BLED, from 37% to 16% for CCS, and from 10% to 2% for CFI. A similar pattern was found in system 2. CONCLUSIONS Using a previously described prediction model to identify patients with high EHR continuity may significantly reduce misclassification for the commonly used risk scores in EHR-based comparative studies.
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Affiliation(s)
- Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dave Merola
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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23
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Kim Y, Song K, Kang CM, Lee H. Impact of preoperative laboratory frailty index on mortality and clinical outcomes in older surgical patients with cancer. Sci Rep 2022; 12:9200. [PMID: 35654943 PMCID: PMC9163125 DOI: 10.1038/s41598-022-13426-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/05/2022] [Indexed: 11/09/2022] Open
Abstract
Frailty in older patients is associated with poor postoperative outcomes. The use of uncomplicated frailty measurement tools is preferred in busy clinical settings. Therefore, we validated the frailty index using routine laboratory data and the surgical outcomes of older patients with cancer who underwent cancer resection. We retrospectively analyzed 9015 patients aged 65 years and older who underwent cancer resection at a single tertiary hospital. Based on electronic-medical-record data regarding preoperative blood test results and vital signs, Laboratory Frailty Index (FI-Lab) scores were generated to measure preoperative frailty. The associations of FI-Lab with postoperative length of stay (LOS), readmission within 30 days, intensive care unit (ICU) admission within 30 days, and mortality were evaluated. The mean FI-Lab score of the 9015 patients was 0.20 ± 0.10. Increased FI-Lab scores (0.25–0.4; > 0.4) were associated with longer LOS, increased readmission within 30 days of surgery, ICU admission, and increased mortality, compared with FI-Lab scores < 0.25. The FI-Lab score, as a frailty indicator, was able to predict the risk of poor postoperative outcomes. Therefore, the FI-Lab is a potentially useful tool for assessing preoperative frailty in older patients with cancer in acute clinical setting.
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Affiliation(s)
- Yoonjoo Kim
- Department of Nursing, Graduate School, Yonsei University, Seoul, South Korea.,Department of Nursing, College of Healthcare Sciences, Far East University, Eumseong-gun, Chungcheongbuk-do, South Korea
| | - Kijun Song
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, South Korea
| | - Chang Moo Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, South Korea
| | - Hyangkyu Lee
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, South Korea.
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24
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Not all is Lost: Dynamic Functional Recovery in Older Adults Following Emergency General Surgery. J Trauma Acute Care Surg 2022; 93:74. [PMID: 35444150 DOI: 10.1097/ta.0000000000003657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Leiner T, Nemeth D, Hegyi P, Ocskay K, Virag M, Kiss S, Rottler M, Vajda M, Varadi A, Molnar Z. Frailty and Emergency Surgery: Results of a Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:811524. [PMID: 35433739 PMCID: PMC9008569 DOI: 10.3389/fmed.2022.811524] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Frailty, a "syndrome of loss of reserves," is a decade old concept. Initially it was used mainly in geriatrics but lately its use has been extended into other specialties including surgery. Our main objective was to examine the association between frailty and mortality, between frailty and length of hospital stay (LOS) and frailty and readmission within 30 days in the emergency surgical population. Methods Studies reporting on frailty in the emergency surgical population were eligible. MEDLINE (via PubMed), EMBASE, Scopus, CENTRAL, and Web of Science were searched with terms related to acute surgery and frail*. We searched for eligible articles without any restrictions on the 2nd of November 2020. Odds ratios (OR) and weighted mean differences (WMD) were calculated with 95% confidence intervals (CI), using a random effect model. Risk of bias assessment was performed according to the recommendations of the Cochrane Collaboration. As the finally selected studies were either prospective or retrospective cohorts, the "Quality In Prognosis Studies" (QUIPS) tool was used. Results At the end of the selection process 21 eligible studies with total 562.070 participants from 8 countries were included in the qualitative and the quantitative synthesis. Patients living with frailty have higher chance of dying within 30 days after an emergency surgical admission (OR: 1.99; CI: 1.76-2.21; p < 0.001). We found a tendency of increased LOS with frailty in acute surgical patients (WMD: 4.75 days; CI: 1.79-7.71; p = 0.002). Patients living with frailty have increased chance of 30-day readmission after discharge (OR: 1.36; CI: 1.06-1.75; p = 0.015). Conclusions Although there is good evidence that living with frailty increases the chance of unfavorable outcomes, further research needs to be done to assess the benefits and costs of frailty screening for emergency surgical patients. Systematic Review Registration The review protocol was registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42021224689).
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Affiliation(s)
- Tamas Leiner
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Anaesthetic Department, Hinchingbrooke Hospital, North West Anglia NHS Foundation Trust, Huntingdon, United Kingdom
| | - David Nemeth
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Peter Hegyi
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division for Pancreatic Disorders, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Marcell Virag
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Department of Anesthesiology and Intensive Therapy, Szent Gyorgy University Teaching Hospital of Fejer County, Szekesfehervar, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Mate Rottler
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Department of Anesthesiology and Intensive Therapy, Szent Gyorgy University Teaching Hospital of Fejer County, Szekesfehervar, Hungary
| | - Matyas Vajda
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Alex Varadi
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Zsolt Molnar
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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26
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Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults. J Am Med Dir Assoc 2022; 23:537-546. [PMID: 35304130 DOI: 10.1016/j.jamda.2022.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 12/24/2022]
Abstract
Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.
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Ylimartimo AT, Lahtinen S, Nurkkala J, Koskela M, Kaakinen T, Vakkala M, Hietanen S, Liisanantti J. Long-term Outcomes After Emergency Laparotomy: a Retrospective Study. J Gastrointest Surg 2022; 26:1942-1950. [PMID: 35697895 PMCID: PMC9489577 DOI: 10.1007/s11605-022-05372-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL. METHODS We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up. RESULTS A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49-74] vs. 71 [63-80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27-3.83]), higher ASA classification (OR 2.37 [1.15-4.88]), higher CCI score (OR 4.74 [3.15-7.14]), and postoperative medical complications (OR 1.61 [1.05-2.47]). CONCLUSIONS Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL.
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Affiliation(s)
- Aura T. Ylimartimo
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O.BOX 21, 90029 OYS Oulu, Finland
| | - Sanna Lahtinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Juho Nurkkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Marjo Koskela
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O.BOX 21, 90029 OYS Oulu, Finland
| | - Timo Kaakinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Siiri Hietanen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland
| | - Janne Liisanantti
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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Kennedy CA, Shipway D, Barry K. Frailty and emergency abdominal surgery: A systematic review and meta-analysis. Surgeon 2021; 20:e307-e314. [PMID: 34980559 DOI: 10.1016/j.surge.2021.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 02/09/2021] [Accepted: 11/29/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Patients aged ≥65 years currently account for approximately 55% of all emergent operations. However, these patients account for 75% of post-operative mortality. Older age has long been associated with adverse outcomes from emergency surgery. However, old age is a heterogenous state. Recent studies have indicated that frailty may more accurately reflect true biological age and perioperative risk than chronological age alone in patients undergoing elective surgery. Few studies have evaluated the impact of frailty on post-operative outcomes in this setting. METHODS A systematic, electronic search for relevant publications was performed in November 2019 using Pubmed and Embase from 2009 to 2019. The latest search for articles was performed on February 16th, 2020. Articles were excluded if frailty was not measured using a frailty tool, or if patients did not undergo emergency general surgery (EGS). RESULTS The prevalence of frailty amongst patients undergoing emergency abdominal surgery was 30.8%. The all-cause mortality rate was 15.68%. The mortality rate amongst the frail undergoing EGS was 24.7%. Frailty was associated with an increased mortality rate compared with the non-frail (odds ratio (OR) 4.3, 95% CI 2.25-8.19%, p < 0.05, I2 = 80%). CONCLUSIONS There is strong evidence to suggest that frailty in the older population predicts post-operative mortality, complications, prolonged length of stay and the loss of independence. Collaborative working with medicine for the elderly physicians to target modifiable aspects of the frailty syndrome in the perioperative pathway may improve outcomes. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.
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Affiliation(s)
| | - David Shipway
- Department of Medicine for Older People, North Bristol NHS Trust, UK; University of Bristol, UK
| | - Kevin Barry
- Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgical Affairs, Royal College of Surgeons, 121-122 St Stephen's Green, Dublin 2, Ireland
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29
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Long-term influence of frailty in elderly patients after surgical emergencies. Eur J Trauma Emerg Surg 2021; 48:3855-3862. [PMID: 34741180 DOI: 10.1007/s00068-021-01818-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 10/25/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Frailty is known to increase vulnerability to stressful factors, and motivate a higher morbidity and mortality in several health conditions. However, long-term impact of frailty after surgical procedures remains unclear. The purpose of this study was to evaluate the relationship between frailty and long-term clinical outcomes after emergency surgery. METHODS Prospective cohort study in patients older than 70 years undergoing emergency procedures. A total of 82 patients (mean age 78.5 years, 53.3% women) were consecutively enrolled. Data on demographics, surgical procedures, complications after 30 postoperative days, and frailty according to the clinical frailty scale, Triage Risk Screening Tool (TRST), and FRAIL scale were recorded. Readmission, mortality, and transition to frailty rates were analyzed at 6 and 18 months postoperatively. RESULTS The prevalence of frailty ranged between 14.6 and 29.6% depending on the scale used. The overall mortality rate at 18 months was 19.5% (16 patients), and the survival curves demonstrated a significant difference in mortality between frail and non-frail patients assessed using the FRAIL scale and TRST (p = 0.049 and p = 0.033, respectively), with a hazard ratio of 2.28 (95% confidence interval 1.24-6.44). Logistic regression analysis showed that diabetes (p = 0.013) was an independent risk factor for transition to frailty, and antidepressant drug use was close to statistical significance (p = 0.08). CONCLUSION Frailty is a predictive marker of long-term mortality in patients undergoing emergency procedures. Diabetes and depression may represent independent risk factors for transition to frailty over time.
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Sokas CM, Hu FY, Dalton MK, Jarman MP, Bernacki RE, Bader A, Rosenthal RA, Cooper Z. Understanding the role of informal caregivers in postoperative care transitions for older patients. J Am Geriatr Soc 2021; 70:208-217. [PMID: 34668189 DOI: 10.1111/jgs.17507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/18/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older adults may have new care needs and functional limitations after surgery. Many rely on informal caregivers (unpaid family or friends) after discharge but the extent of informal support is unknown. We sought to examine the role of informal postoperative caregiving on transitions of care for older adults undergoing routine surgical procedures. MATERIALS AND METHODS We performed a retrospective cohort study using ACS NSQIP Geriatric Pilot Project data, 2014-2018. Patients were ≥65 years and underwent an inpatient surgical procedure. Patients who lived at home alone were compared with those who lived with support from informal caregivers (family and/or friends). Primary outcomes were discharge destination (home vs. post-acute care) and readmission within 30 days. Multivariable logistic regression was used to determine the association between support at home, discharge destination, and readmission. RESULTS Of 18,494 patients, 25% lived alone before surgery. There was no difference in loss of independence (decline in functional status or new use of mobility aid) after surgery between patients who lived alone or with others (18.7% vs. 19.5%, p = 0.24). Nevertheless, twice as many patients who lived alone were discharged to a non-home location (10.2% vs. 5.1%; OR: 2.24, CI: 1.93-2.56). Patients who lived alone and were discharged home with new informal caregivers had increased odds of readmission (OR: 1.43, CI: 1.09-1.86). CONCLUSION Living alone independently predicts discharge to post-acute care, and patients who received new informal caregiver support at home have higher odds of readmission. These findings highlight opportunities to improve discharge planning and care.
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Affiliation(s)
- Claire M Sokas
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Frances Y Hu
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Michael K Dalton
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Angela Bader
- Department of Anesthesia, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | | | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
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Abstract
BACKGROUND Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients. OBJECTIVE In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program. METHODS The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities. RESULTS A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (≥85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (≥90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019. CONCLUSION This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs.
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The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3755-3762. [PMID: 34398335 DOI: 10.1007/s00586-021-06960-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/29/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. METHODS The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals. CONCLUSIONS Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.
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External Prospective Validation of the Modified CriSTAL Score for 30- and 90-day Mortality in Geriatric Urgent Surgical Patients. J Gastrointest Surg 2021; 25:2083-2090. [PMID: 33111261 DOI: 10.1007/s11605-020-04822-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/01/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aimed to determine the predictive accuracy of the modified clinical prognostic tool Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) to predict 30-day and 90-day mortality in older patients undergoing urgent abdominal surgery. BACKGROUND Anticipating the mid-term mortality of older patients undergoing urgent surgery is complex and flawed with uncertainty. METHODS A prospective study of consecutive ≥ 65 years old presenting at the emergency department who subsequently underwent urgent abdominal surgery. The modified CriSTAL score was calculated in the sample using the FRAIL scale instead of the Clinical Frailty Scale. Discrimination (area under the receiver-operating characteristic (AUROC)) and model calibration were used to test the predictive accuracy of the modified CriSTAL score for death within 30-day mortality as the primary outcome. RESULTS A total of 500 patients (median age 78 years) were enrolled. The observed 30-day and 90-day mortality rate were 11.6% and 13.6%. The modified CriSTAL tool AUROC curve to predict 30-day and 90-day mortality was 0.78 and 0.77. The model was well calibrated according to the Hosmer-Lemeshow test (p: 0.302) and the calibration plots to predict 30-day and 90-day mortality. CONCLUSIONS The modified CriSTAL tool (with FRAIL scale as frailty instrument) had good discriminant power and was well calibrated to predict 30-day and 90-day mortality in elderly patients undergoing urgent abdominal surgery. The modified CriSTAL tool is an easy preoperative tool that could assist in the prognosis of postoperative outcomes and decision-making discussions with patients before for urgent abdominal surgery.
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Sokas C, Lee KC, Sturgeon D, Streid J, Lipsitz SR, Weissman JS, Kim DH, Cooper Z. Preoperative Frailty Status and Intensity of End-of-Life Care Among Older Adults After Emergency Surgery. J Pain Symptom Manage 2021; 62:66-74.e3. [PMID: 33212144 PMCID: PMC8124083 DOI: 10.1016/j.jpainsymman.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022]
Abstract
CONTEXT Emergency general surgery (EGS) is common and highly morbid for older adults, particularly for those who are frail. However, there are little data on the quality of end-of-life care (EOLC) for this population. OBJECTIVES We sought to examine the association of frailty with intensity of EOLC for older adults with and without frailty who undergo EGS but die within one year. METHODS This retrospective cohort study included 100% Medicare fee-for-service beneficiaries, ≥66 years, who underwent one of five EGS procedures with the highest mortality (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy) between 2008 and 2014 and died within one year. A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < 0.15), prefrail (0.15 ≤ CFI < 0.25), mildly frail (0.25 ≤ CFI < 0.35), and moderately to severe frail (CFI ≥ 0.35). Multivariable adjusted logistic or Poisson regression compared post-discharge and EOL healthcare utilization. RESULTS Among 138,916 older EGS adults who died within one year, 32.2% were not frail, 31.7% were prefrail, 29.8% had mild frailty and 6.3% had moderate-to-severe frailty. Decedents with any degree of frailty experienced high-intensity EOLC (P < 0.01), low rates of hospice use (P < 0.01), and fewer days at home. Of those who survived the index hospitalization but died within one year, moderate-to-severely frail decedents had the highest odds of visiting an emergency department (odds ratio [OR] = 1.19, CI = 1.13-1.27), rehospitalization (OR = 1.23, CI = 1.16-1.31), or an intensive care unit admission (OR = 1.22, CI = 1.13-1.30) in the last 30 days of life compared to nonfrail decedents. CONCLUSION While all older patients undergoing EGS have poor end-of-life outcomes, frail EGS patients receive the highest intensity EOLC and represent a vulnerable population for whom targeted interventions could limit burdensome treatment.
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Affiliation(s)
- Claire Sokas
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Daniel Sturgeon
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Stuart R Lipsitz
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joel S Weissman
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dae H Kim
- Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Chan V, Wilson JRF, Ravinsky R, Badhiwala JH, Jiang F, Anderson M, Yee A, Wilson JR, Fehlings MG. Frailty adversely affects outcomes of patients undergoing spine surgery: a systematic review. Spine J 2021; 21:988-1000. [PMID: 33548521 DOI: 10.1016/j.spinee.2021.01.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/16/2020] [Accepted: 01/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND With an aging population, there are an increasing number of elderly patients undergoing spine surgery. Recent literature in other surgical specialties suggest frailty to be an important predictor of outcomes. PURPOSE The aim of this review was to examine the association between frailty and outcomes after spine surgery. STUDY DESIGN A systematic review was performed. PATIENT SAMPLE Electronic databases from 1946 to 2020 were searched to identify articles on frailty and spine surgery. OUTCOME MEASURES The primary outcome was adverse events. Secondary outcomes included other measures of morbidity, mortality, and patient outcomes. METHODS Sample size, mean age, age limitation, data source, study design, primary pathology, surgical procedure performed, follow-up period, assessment of frailty used, surgical outcomes, and impact of frailty on outcomes were extracted from eligible studies. Quality and bias were assessed using the PRISMA 27-point item checklist and the QUADAS-2 tool. RESULTS Thirty-two studies were selected for review, with a total of 127,813 patients. There were eight different frailty indices/measures. Regardless of how frailty was measured, frailty was associated with an increased risk of adverse events, mortality, extended length of stay, readmission, and nonhome discharge. CONCLUSION There is strong evidence that frailty is associated with an increased risk of morbidity and mortality in patients who received spine surgery. However, it remains inconclusive whether frailty impacts patient outcomes and quality of life after surgery.
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Affiliation(s)
- Vivien Chan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8
| | - Jamie R F Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8
| | - Robert Ravinsky
- Department of Orthopaedic Surgery, University of Arizona College of Medicine - Phoenix, 755 E. McDowell Rd, 2nd Floor, Phoenix, AZ,85006; Spine Division, The CORE Institute, 18444 N. 25th Ave, suite 210, Phoenix, AZ, 85023
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8
| | - Fan Jiang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8
| | - Melanie Anderson
- Library and Information Services, University Health Network, Toronto, Ontario, M5T 2S8
| | - Albert Yee
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Department of Orthopedic Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, M4N 3M5
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Department of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, M5B 1W8
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 2S8; Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, M5T 2S8.
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Kenawy DM, Renshaw SM, George E, Malik AT, Collins CE. Increasing Frailty in Geriatric Emergency General Surgery: A Cause for Concern. J Surg Res 2021; 266:320-327. [PMID: 34052600 DOI: 10.1016/j.jss.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/05/2021] [Accepted: 04/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. MATERIALS AND METHODS A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5 = 0, mFI-5 = 1, mFI-5 = 2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. RESULTS A total of 47,216 patients were included: 27.4% with mFI-5 = 0, 45% with mFI-5 = 1, 22.1% with mFI-5 = 2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5 = 1: odds ratio (OR) 1.48, p=0.003; mFI-5 = 2: OR 2.66, p <0.001; mFI-5 ≥ 3: OR 3.97, p <0.001), 30-day complications (mFI-5 = 1: OR 1.46, p <0.001; mFI-5 = 2: OR 2.48, p <0.001; mFI-5≥3: OR 5.01, p <0.001), reoperation (mFI-5 = 1: OR 1.42, p = 0.020; mFI-5 = 2: OR 1.70, p = 0.021; mFI-5 ≥ 3: OR 2.18, p = 0.009) and all-cause mortality (mFI-5 = 1: OR 1.49, p=0.001; mFI-5 = 2: OR 2.67, p <0.001; mFI-5 ≥ 3: 3.96, p <0.001). CONCLUSIONS Increasing frailty in geriatric EGS patients is associated with significantly higher rates of FTR, 30-day complications, reoperations, and all-cause mortality. The mFI-5 score can be used to assess frailty and better anticipate the postoperative course of vulnerable geriatric patients.
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Affiliation(s)
- Dahlia M Kenawy
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Savannah M Renshaw
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Emily George
- College of Medicine, The Ohio State University, Columbus, OH
| | - Azeem Tariq Malik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Courtney E Collins
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Sokas C, Yeh IM, Coogan K, Bernacki R, Mitchell S, Bader A, Ladin K, Palmer JA, Tulsky JA, Cooper Z. Older Adult Perspectives on Medical Decision Making and Emergency General Surgery: "It had to be Done.". J Pain Symptom Manage 2021; 61:948-954. [PMID: 33038427 PMCID: PMC8024409 DOI: 10.1016/j.jpainsymman.2020.09.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT Optimal surgical care for older adults with life-threatening conditions, with high risk of poor perioperative outcomes and morality in the months after surgery, should incorporate an understanding of the patient's treatment goals and preferences. However, little research has explored the patient perspective of decision making and advanced care planning during an emergency surgery episode. OBJECTIVES We sought to better understand older patients' lived experience making decisions to undergo emergency general surgery (EGS) and perceptions of perioperative advance care planning (ACP). METHODS Adults aged 65 and older who underwent one of seven common EGS procedures with lengths of stay more than five days at three Boston-area hospitals were included. Semistructured phone interviews were conducted three months postdischarge. Transcripts were reviewed and coded independently by surgeons and palliative care physicians to identify themes. RESULTS About 31 patients were interviewed. Patients viewed the decision for surgery as a choice of life over death and valued prolonging life. They felt there was no choice but to proceed with surgery but reported that participation in decision making was limited because of severe symptoms, time constraints, and confused thinking. Despite recently surviving a life-threatening illness, patients had not reconsidered their wishes for the future and preferred to avoid future ACP. CONCLUSION Older patients who survived a life-threatening illness and EGS report receiving goal-concordant care in the moment that relieved symptoms and prolonged life but had not considered future care. Interventions to facilitate postoperative ACP should be targeted to this vulnerable group of older adults.
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Affiliation(s)
- Claire Sokas
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Irene M Yeh
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kathleen Coogan
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Rachelle Bernacki
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Susan Mitchell
- Hebrew SeniorLife Arthur and Hinda Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Angela Bader
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA; Department of Anesthesia, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| | - Jennifer A Palmer
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA; Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James A Tulsky
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zara Cooper
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA; Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA.
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Alive and at home: Five-year outcomes in older adults following emergency general surgery. J Trauma Acute Care Surg 2021; 90:287-295. [PMID: 33502146 DOI: 10.1097/ta.0000000000003018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship. METHODS We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models. RESULTS A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17-5.11). CONCLUSION Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Matthew P Guttman
- From the Institute of Health Policy, Management, and Evaluation (M.P.G., B.W.T., A.B.N., S.E.B., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), and Interdepartmental Division of Critical Care Medicine, Department of Medicine (B.W.T., B.H.), University of Toronto; Evaluative Clinical Sciences, Sunnybrook Research Institute (A.B.N., S.E.B., B.H.), Toronto, Ontario, Canada; American College of Surgeons, Trauma Quality Improvement Program (A.B.N.), Chicago, Illinois; and ICES Central, ICES (R.S., S.E.B., A.H.), Toronto, Ontario, Canada
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Cheung C, Meissner MA, Garg T. Incorporating Outcomes that Matter to Older Adults into Surgical Research. J Am Geriatr Soc 2021; 69:618-620. [PMID: 33462830 DOI: 10.1111/jgs.17028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Carling Cheung
- Department of Urology, Geisinger, Danville, Pennsylvania, USA
| | | | - Tullika Garg
- Department of Urology, Geisinger, Danville, Pennsylvania, USA.,Department of Population Health Sciences, Geisinger, Danville, Pennsylvania, USA
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Price A. Improving outcomes for older people undergoing emergency surgery: Opportunities for advanced practice. J Adv Nurs 2020; 77:504-505. [PMID: 33249642 DOI: 10.1111/jan.14686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Angeline Price
- Salford Royal Hospital Ringgold Standard Institution - Ageing and Complex Medicine, Salford, UK
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Emergency laparotomy in the older patient: factors predictive of 12-month mortality-Salford-POPS-GS. An observational study. Aging Clin Exp Res 2020; 32:2367-2373. [PMID: 32449105 PMCID: PMC7591437 DOI: 10.1007/s40520-020-01578-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/25/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Although high rates of in-hospital mortality have been described in older patients undergoing emergency laparotomy (EL), less is known about longer-term outcomes in this population. We describe factors present at the time of hospital admission that influence 12-month survival in older patients. METHODS Observational study of patients aged 75 years and over, who underwent EL at our hospital between 8th September 2014 and 30th March 2017. RESULTS 113 patients were included. Average age was 81.9 ± 4.7 years, female predominance (60/113), 3 (2.6%) lived in a care home, 103 (91.2%) and 79 (69.1%) were independent of personal and instrumental activities of daily living (ADLs) and 8 (7.1%) had cognitive impairment. Median length of stay was 16 days ± 29.9 (0-269); in-hospital mortality 22.1% (25/113), post-operative 30-day, 90-day and 12-month mortality rates 19.5% (22), 24.8% (28) and 38.9% (44). 30-day and 12-month readmission rates 5.7% (5/88) and 40.9% (36). 12-month readmission was higher in frail patients, using the Clinical Frailty Scale (CFS) score (64% 5-8 vs 31.7% 1-4, p = 0.006). Dependency for personal ADLs (6/10 (60%) dependent vs. 38/103 (36.8%) independent, p = 0.119) and cognitive impairment (5/8 (62.5%) impaired vs. 39/105 (37.1%) no impairment, p = 0.116) showed a trend towards higher 12-month mortality. On multivariate analysis, 12-month mortality was strongly associated with CFS 5-9 (HR 5.0403 (95% CI 1.719-16.982) and ASA classes III-V (HR 2.704 95% CI 1.032-7.081). CONCLUSION Frailty and high ASA class predict increased mortality at 12 months after emergency laparotomy. We advocate early engagement of multi-professional teams experienced in perioperative care of older patients.
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