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Lodge M, Aitken R, Chong YH, Thillainadesan J. Development of a minimum clinical dataset for preoperative comprehensive geriatric assessment using a modified Delphi technique. Australas J Ageing 2024. [PMID: 38754868 DOI: 10.1111/ajag.13334] [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: 02/29/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To construct a standardised, consensus-guided minimum clinical dataset (MCDS) for preoperative comprehensive geriatric assessment and optimisation (CGA) in Australia and Aotearoa New Zealand. METHODS We conducted a review of the international perioperative literature to identify CGA domains and tools for potential inclusion in the MCDS. We invited members of the Australian and New Zealand Society for Geriatric Medicine to participate in a Delphi study to obtain consensus on MCDS tools. Participants were asked to rate proposed tools using Likert scales (when >2 tools) or make a binary choice between two proposed tools. Consensus was considered to be achieved when there was at least 75% concordance between the two rounds amongst the participants, and at least one variable attaining over 50% of participants' votes. Domains that did not achieve consensus in Round 1 were carried over to Round 2. RESULTS There were 73 participants in Round 1 of the Delphi study and 47 participants in Round 2. Consensus was achieved on tool/s recommended for every MCDS domain: Clinical Frailty Scale (frailty); sMMSE, RUDAS, MoCA (cognition); 4AT (delirium); timed-up-and-go (physical function); GDS-15 (mood); Barthel Index (functional status); and MUST (malnutrition). CONCLUSIONS We recommend clinicians delivering preoperative CGA consider the use of the MCDS we have constructed when assessing older people contemplating surgery, as part of a multicomponent and multidisciplinary approach to optimising perioperative outcomes.
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Affiliation(s)
- Margot Lodge
- Alfred Health, Melbourne, Victoria, Australia
- National Centre for Healthy Ageing, Melbourne, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rachel Aitken
- Department of Aged Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Yih Harng Chong
- Te Whatu Ora (Waitemata District), Auckland, New Zealand
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Janani Thillainadesan
- Department of Geriatric Medicine, Centre for Education and Research on Ageing, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Foley MP, Westby D, Walsh SR. Systematic Review and Meta-analysis of the Impact of Surgeon-Physician Co-management Models on Short Term Outcomes for Vascular Surgery Inpatients. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00383-6. [PMID: 38735522 DOI: 10.1016/j.ejvs.2024.05.005] [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: 08/15/2023] [Revised: 04/19/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE As the population ages, vascular surgeons are treating progressively older, multimorbid patients at risk of peri-operative complications. An embedded physician has been shown to improve outcomes in general and orthopaedic surgery. This systematic review and meta-analysis aimed to investigate the impact of surgeon-physician co-management models on morbidity and mortality rates in vascular inpatients. DATA SOURCES PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries. REVIEW METHODS Studies comparing adult vascular surgery inpatients under co-management with standard of care were eligible. The relative risks (RRs) of death, medical complications, and 30 day re-admission between co-management and standard care were calculated. The effect of co-management on the mean length of stay was calculated using weighted means. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies, and certainty assessment with the GRADE analysis tools. RESULTS No randomised controlled trials were identified. Eight single institution studies between 2011 and 2020 with 7 410 patients were included. All studies were observational using before-after methodology. Studies were of high to moderate risk of bias, and outcomes were of very low GRADE certainty of evidence. Co-management was associated with a statistically significant lower relative risk of death (RR 0.64, 95% confidence interval [CI] 0.44 - 0.92; p = .02), cardiac complications (RR 0.47, 95% CI 0.25 - 0.87; p = .02), and infective complications (RR 0.49, 95% CI 0.35 - 0.67; p < .001) in vascular inpatients. No statistically significant differences in length of stay (standard mean difference -0.6 days, 95% CI -1.44 - 0.24 days; p = .16) and 30 day re-admission (RR 0.96, 95% CI 0.84 - 1.08; p = .49) were noted. CONCLUSION Early results of physician and surgeon co-management for vascular surgery inpatients showed promising results from very low certainty data. Further well designed, prospective studies are needed to determine how to maximise the impact of physicians within a vascular service to improve patient outcomes while using hospital resources effectively.
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Affiliation(s)
- Megan Power Foley
- University College Hospital Galway, Galway, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | | | - Stewart R Walsh
- University College Hospital Galway, Galway, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; Lambe Institute of Translational Research, University of Galway, Galway, Ireland; National Surgical Research Support Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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Mao D, Rey-Conde T, North JB, Lancashire RP, Naidu S, Chua T. Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study. ANZ J Surg 2024; 94:684-690. [PMID: 38149760 DOI: 10.1111/ans.18835] [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: 07/10/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death. METHODS Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death. RESULTS In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death. CONCLUSION Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.
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Affiliation(s)
- Derek Mao
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Therese Rey-Conde
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, Queensland, Australia
| | - John B North
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, Queensland, Australia
| | - Raymond P Lancashire
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Sanjeev Naidu
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - Terence Chua
- Department of General Surgery, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Lodge ME, Dhesi J, Shipway DJ, Braude P, Meilak C, Partridge J, Andrew NE, Srikanth V, Ayton DR, Moran C. The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study. BMC Health Serv Res 2024; 24:345. [PMID: 38491431 PMCID: PMC10943911 DOI: 10.1186/s12913-024-10844-0] [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: 12/09/2023] [Accepted: 03/08/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK. METHODS A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR). RESULTS Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services. CONCLUSIONS Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.
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Affiliation(s)
- Margot E Lodge
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - David Jh Shipway
- CLARITY (Collaborative Ageing Research) group, North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
| | - Philip Braude
- CLARITY (Collaborative Ageing Research) group, North Bristol NHS Trust, Bristol, UK
| | - Catherine Meilak
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Judith Partridge
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Nadine E Andrew
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
| | - Velandai Srikanth
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Peninsula Health, Frankston, Australia
| | - Darshini R Ayton
- National Centre for Healthy Ageing, Melbourne, Australia.
- Health and Social Care Unit, Monash University, Melbourne, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Chris Moran
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
- Peninsula Health, Frankston, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Khanderia E, Aggarwal R, Bouras G, Patel V. Quality of life after emergency laparotomy: a systematic review. BMC Surg 2024; 24:73. [PMID: 38409008 PMCID: PMC10898072 DOI: 10.1186/s12893-024-02337-y] [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: 11/05/2023] [Accepted: 01/30/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Emergency laparotomy is a commonly performed surgical procedure that has higher post-operative morbidity and mortality than elective surgery. Previous research has identified that patients valued postoperative quality of life (QoL) more than the risk of mortality when deciding to undergo emergency surgery. Current pre-operative scoring and risk stratification systems for emergency laparotomy do not account for or provide prediction tools for post-operative QoL. This study aims to systematically review previous literature to determine post-operative QoL in patients who undergo emergency laparotomy. METHODS A literature search was undertaken in Medline, EMBASE and the Cochrane Library to identify studies measuring post-operative QoL in patients who have had emergency laparotomy up to 29th April 2023. Mean QoL scores from the studies included were combined to calculate the average effect of emergency laparotomy on QoL. The primary outcome of the review was postoperative QoL after emergency laparotomy when compared with a comparator group. Secondary outcomes included the quality of included studies. RESULTS Ten studies in the literature assessing the QoL of patients after emergency laparotomy were identified. Three studies showed that patients had improved QoL and seven showed worse QoL following emergency laparotomy. Length of time for QoL to return to baseline varied ranged from 3 to 12 months post-operatively. Length of hospital stay was identified as an independent risk factor for poorer QoL post-surgery. CONCLUSIONS Outcome reporting for patients who undergo emergency laparotomy should be expanded further to include QoL. Further work is required to investigate this and elicit factors that can improve QoL post-operatively.
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Affiliation(s)
- Esha Khanderia
- Watford General Hospital, West Hertfordshire Teaching Hospitals NHS Trust, Watford, UK.
| | - Ravi Aggarwal
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - George Bouras
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Vanash Patel
- Watford General Hospital, West Hertfordshire Teaching Hospitals NHS Trust, Watford, UK
- Department of Surgery & Cancer, Imperial College London, London, UK
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Jayasinghe G, Kumar R, Buckle C, Vinayakam P, Slack R. Patient mortality after total hip arthroplasty revision surgery. J Orthop 2024; 47:45-49. [PMID: 38022843 PMCID: PMC10679522 DOI: 10.1016/j.jor.2023.11.020] [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: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Complications following revision total hip arthroplasty can cause significant morbidity and have a high mortality rate. Patient age and American Society of Anaesthesiologists (ASA) physical status classification system score are important determinants of mortality following revision hip arthroplasty. There is a paucity of high-quality evidence assessing the risk of mortality following revision hip arthroplasty stratified by indications of surgery. The aim of this study is to compare survival of patients undergoing revision THA for different indications. Methods This retrospective case series reviewed the mortality rate following revision hip surgery performed by a single surgeon between 2009 and 2016 with a minimum 2 year follow up. Kaplan Meir analysis was performed using mortality as the end point. Log rank testing was used to determine if the indication for surgery conferred a difference in survival. Results One hundred and ninety-eight consecutive cases were done using a tapered modular uncemented stem in 183 patients and were followed up for a mean period of 51.8 months (range, 24-121). Sixty patients died (67 % survivorship) during the follow up period with a 5-year survival rate of 78 %. Revision surgery performed for aseptic loosening had the best survival and hemiarthroplasty had the worst and differences in survival were statistically significant (P = 0.000002). Conclusion The indication for revision surgery is an important criterion which must be given weightage along with age, functional status of patient and ASA physical status score while planning revision surgery and counselling patients.
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Affiliation(s)
- Gihan Jayasinghe
- Queen Elizabeth The Queen Mother Hospital, Ramsgate Road, Margate, CT9 4AN, UK
| | - Rohit Kumar
- William Harvey Hospital, Kennington Road, Willesborough, Ashford, TN24 0LZ, UK
| | - Chris Buckle
- Queen Elizabeth The Queen Mother Hospital, Ramsgate Road, Margate, CT9 4AN, UK
| | - Parthiban Vinayakam
- Queen Elizabeth The Queen Mother Hospital, Ramsgate Road, Margate, CT9 4AN, UK
| | - Richard Slack
- Queen Elizabeth The Queen Mother Hospital, Ramsgate Road, Margate, CT9 4AN, UK
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Swarbrick C, Poulton T, Martin P, Partridge J, Moppett IK. Study protocol for a national observational cohort investigating frailty, delirium and multimorbidity in older surgical patients: the third Sprint National Anaesthesia Project (SNAP 3). BMJ Open 2023; 13:e076803. [PMID: 38135325 DOI: 10.1136/bmjopen-2023-076803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Older surgical patients are more likely to be living with frailty and multimorbidity and experience postoperative complications. The management of these conditions in the perioperative pathway is evolving. In order to support objective decision-making for patients, services and national guidance, accurate, contemporary data are needed to describe the impact and associations between frailty, multimorbidity and healthcare processes with patient and service-level outcomes. METHODS AND ANALYSIS The study is comprised of an observational cohort study of approximately 7500 patients; an organisational survey of perioperative services and a clinician survey of the unplanned, medical workload generated from older surgical patients. The cohort will consist of patients who are 60 years and older, undergoing a surgical procedure during a 5-day recruitment period in participating UK hospitals. Participants will be assessed for baseline frailty and multimorbidity; postoperative morbidity including delirium; and quality of life. Data linkage will provide additional details about individuals, their admission and mortality.The study's primary outcome is length of stay, other outcome measures include incidence of postoperative morbidity and delirium; readmission, mortality and quality of life. The cohort's incidence of frailty, multimorbidity and delirium will be estimated using 95% CIs. Their relationships with outcome measures will be examined using unadjusted and adjusted multilevel regression analyses. Choice of covariates in the adjusted models will be prespecified, based on directed acyclic graphs.A parallel study is planned to take place in Australia in 2022. ETHICS AND DISSEMINATION The study has received approval from the Scotland A Research Ethics Committee and Wales Research Ethics Committee 7.This work hopes to influence the development of services and guidelines. We will publish our findings in peer-reviewed journals and provide summary documents to our participants, sites, healthcare policy-makers and the public. TRIAL REGISTRATION NUMBER ISRCTN67043129.
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Affiliation(s)
- Claire Swarbrick
- Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
- Anaesthesia, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Tom Poulton
- Anaesthesia, Perioperative Medicine, and Pain Medicine, Victorian Comprehensive Cancer Centre, University of Melbourne, Parkville, Victoria, Australia
- Critical Care, University College London, London, UK
| | - Peter Martin
- Applied Health Research, University College London, London, UK
| | - Judith Partridge
- Division of Health and Social Care Research, King's College London, London, UK
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Iain Keith Moppett
- Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
- Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Warner RL, Iwanyshyn N, Johnson D, Skarupa DJ. Optimization of Care for the Elderly Surgical Emergency Patient. Surg Clin North Am 2023; 103:1253-1267. [PMID: 37838466 DOI: 10.1016/j.suc.2023.05.017] [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
Geriatric patients undergoing emergency surgery are at significantly higher risk for complications and death when compared with younger patients. Optimizing care for these patients requires a multidisciplinary team, special attention to physiologic changes and medication use, as well as targeted intervention to mitigate complications such as delirium, which can worsen overall outcomes. Frailty can be assessed preoperatively to identify patients at the highest risk for complications. Shared decision-making with both the family and patient during the consent process is integral to defining patient's goals of care in these high-risk situations.
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Affiliation(s)
- Rachel Lynne Warner
- University of Florida College of Medicine -Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Nadia Iwanyshyn
- University of Florida College of Pharmacy -Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Donald Johnson
- University of Florida College of Pharmacy -Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - David J Skarupa
- University of Florida College of Medicine -Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.
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Tian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E, Bensard D, Sakakushev B, Galante J, Fraga GP, Koike K, Di Carlo I, Tebala GD, Leppaniemi A, Tan E, Damaskos D, De'Angelis N, Hecker A, Pisano M, Maier RV, De Simone B, Amico F, Ceresoli M, Pikoulis M, Weber DG, Biffl W, Beka SG, Abu-Zidan FM, Valentino M, Coccolini F, Kluger Y, Sartelli M, Agnoletti V, Chirica M, Bravi F, Sall I, Catena F. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg 2023; 18:38. [PMID: 37355698 DOI: 10.1186/s13017-023-00506-7] [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: 03/30/2023] [Accepted: 05/27/2023] [Indexed: 06/26/2023] Open
Abstract
Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.
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Affiliation(s)
- Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Philip F Stahel
- Department of Orthopedic Surgery and Department of Neurosurgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy
| | - Giovanni D Tebala
- Oxford University Hospitals NHSFT John Radcliffe Hospital, Headley Way, HeadingtonOxford, OX3 9DU, UK
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola De'Angelis
- Hôpital Henri Mondor, Université Paris Est, Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Créteil, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital, Giessen, Germany
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ron V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walt Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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10
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Perioperative medicine for Older People undergoing Surgery (POPS): Comprehensive Geriatric Assessment (CGA) and optimization in the perioperative setting. Int Anesthesiol Clin 2023; 61:62-69. [PMID: 36892984 DOI: 10.1097/aia.0000000000000396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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11
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Ibitoye SE, Braude P, Carter B, Rickard F, Deakin H, Martin R, Thompson J, Walton B, Shipway D. Geriatric Assessment Is Associated With Reduced Mortality at 1 Year for Older Adults Admitted to a Major Trauma Center: A Prospective Observational Study. Ann Surg 2023; 277:343-349. [PMID: 36745762 DOI: 10.1097/sla.0000000000005092] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the effect of geriatrician review on 1-year mortality in older adults admitted with trauma. BACKGROUND Comprehensive geriatric assessment (CGA) has been associated with improved outcomes in older adults with hip fracture, but has not been evaluated in a broader trauma population. METHODS Trauma patients aged ≥ 65years admitted to an English Major Trauma Centre between November 2018 and September 2019 were included. Patients were divided into 3 cohorts: no geriatric assessment, reactive geriatric assessment, and proactive CGA. The primary outcome was time to mortality, secondary outcomes were time to discharge and frequency of complications. Analyses were adjusted for factors known to be associated with outcomes including age, frailty, injury severity, and complications. RESULTS Five hundred eighty-five patients were included (no geriatric assessment = 125; reactive geriatric assessment = 134; proactive CGA = 326): median age was 81 years (IQR 74-88); 326 (55.7%) were women; 297 (50.8%) were living with frailty (Clinical Frailty Scale ≥5). Median Injury Severity Score was 13 (IQR9-25). At 1-year follow-up, 147 (25.1%) patients had died. In multivariate analysis, both types of geriatric assessment were associated with reduced mortality [reactive aHR = 0.31, 95% CI 0.18-0.53; proactive adjusted hazard ratio (aHR) = 0.41, 95% CI 0.26-0.64]. There was no association between either type of geriatric assessment and length of stay (reactive aHR = 0.84, 95% CI 0.62-1.15; proactive aHR = 0.80, 95% CI 0.63-1.02). CONCLUSIONS Geriatrician assessment is associated with reduced mortality in older adults admitted following trauma. Further research should focus on defining optimal models of geriatrician intervention.
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Affiliation(s)
- Sarah E Ibitoye
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Philip Braude
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Frances Rickard
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Helen Deakin
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Rebecca Martin
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Julian Thompson
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Benjamin Walton
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - David Shipway
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK.,University of Bristol, Bristol, UK
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12
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Viswanath M, Clinch D, Ceresoli M, Dhesi J, D’Oria M, De Simone B, Podda M, Di Saverio S, Coccolini F, Sartelli M, Catena F, Moore E, Rangar D, Biffl WL, Damaskos D. Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey. World J Emerg Surg 2023; 18:7. [PMID: 36653865 PMCID: PMC9850554 DOI: 10.1186/s13017-022-00471-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/25/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Frailty is associated with poor post-operative outcomes in emergency surgical patients. Shared multidisciplinary models have been developed to provide a holistic, reactive model of care to improve outcomes for older people living with frailty. We aimed to describe current perioperative practices, and surgeons' awareness and perception of perioperative frailty management, and barriers to its implementation. METHODS A qualitative cross-sectional survey was sent via the World Society of Emergency Surgery e-letter to their members. Responses were analysed using descriptive statistics and reported by themes: risk scoring systems, frailty awareness and assessment and barriers to implementation. RESULT Of 168/1000 respondents, 38% were aware of the terms "Perioperative medicine for older people undergoing surgery" (POPS) and Comprehensive Geriatric Assessment (CGA). 66.6% of respondents assessed perioperative risk, with 45.2% using the American Society of Anaesthesiologists Physical Status Classification System (ASA-PS). 77.8% of respondents mostly agreed or agreed with the statement that they routinely conducted medical comorbidity management, and pain and falls risk assessment during emergency surgical admissions. Although 98.2% of respondents agreed that frailty was important, only 2.4% performed CGA and 1.2% used a specific frailty screening tool. Clinical frailty score was the most commonly used tool by those who did. Screening was usually conducted by surgical trainees. Key barriers included a lack of knowledge about frailty assessment, a lack of clarity on who should be responsible for frailty screening, and a lack of trained staff. CONCLUSIONS Our study highlights the ubiquitous lack of awareness regarding frailty assessment and the POPS model of care. More training and clear guidelines on frailty scoring, alongside support by multidisciplinary teams, may reduce the burden on surgical trainees, potentially improving rates of appropriate frailty assessment and management of the frailty syndrome in emergency surgical patients.
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Affiliation(s)
| | - Darja Clinch
- grid.418716.d0000 0001 0709 1919Registrar in General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Marco Ceresoli
- grid.7563.70000 0001 2174 1754General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Jugdeep Dhesi
- grid.420545.20000 0004 0489 3985Department of Ageing and Health, Guy’s and St Thomas NHS Foundation Trust, London, UK
| | - Mario D’Oria
- grid.460062.60000000459364044Division of Vascular and Endovascular Surgery, Cardiovascular Departments, University Hospital of Trieste, ASUGI, Trieste, Italy
| | - Belinda De Simone
- Unit of Digestive and Bariatric Surgery, Clinique Saint Louis, Poissy, Île-de-France France
| | - Mauro Podda
- grid.7763.50000 0004 1755 3242Emergency Surgery Unit, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Salomone Di Saverio
- Hospital of San Benedetto del Tronto, AV5 ASUR Marche, San Benedetto del Tronto, Italy
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Fausto Catena
- grid.414682.d0000 0004 1758 8744General and Emergency Surgery Dept, Bufalini Hospital, Cesena, Italy
| | - Ernest Moore
- grid.239638.50000 0001 0369 638XDenver Health System-Denver Health Medical Center, Denver, USA
| | - Deepa Rangar
- grid.418716.d0000 0001 0709 1919Medicine of the Elderly, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Walter L. Biffl
- grid.415402.60000 0004 0449 3295Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Dimitrios Damaskos
- grid.418716.d0000 0001 0709 1919Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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13
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Shahab R, Lochrie N, Moppett IK, Dasgupta P, Partridge JSL, Dhesi JK. A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients. J Am Med Dir Assoc 2022; 23:1948-1954.e4. [PMID: 36137559 DOI: 10.1016/j.jamda.2022.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/12/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Comprehensive Geriatric Assessment (CGA), a multicomponent, complex intervention, can be used to improve perioperative outcomes. This study aimed to describe the actions and interventions prompted by preoperative CGA and optimization in elective noncardiac, older, surgical patients. DESIGN Retrospective observational study. SETTING AND PARTICIPANTS Five hundred consecutive patients aged over 65 years attending a preoperative CGA and optimization clinic in a single academic center. METHODS A retrospective review of electronic clinical records was undertaken. CGA prompted actions and interventions were categorized a priori and examined according to the perioperative pathway and frailty status. RESULTS Patients received a median of nine interventions (IQR 6‒12, range 0‒28). Long-term condition medication changes were made in 375 (75.0%) patients, lifestyle advice provided in 269 (53.8%), therapy interventions delivered in 117 (23.4%), shared decision making documented in 495 (99.0%) with individualized admission plans documented in 410/426 (96.2%). Following CGA, 74/500 (14.8%) patients did not undergo surgery and were more likely to have benign pathology (69% vs 53%, P = .01), higher frailty scores (Edmonton Frail Scale 8 (IQR 5‒10) vs 4 (IQR 2-6), P < .001), lower functional status (Nottingham Extended Activities of Daily Living 33 (IQR 16‒47) vs 57 (IQR 45‒64), P < .001) or cognitive scores (Montreal Cognitive Assessment 19 (IQR 14‒24) vs 24 (IQR 20‒26), P < .001). CONCLUSIONS AND IMPLICATIONS This study provides a description of actions and interventions prompted by preoperative CGA at one center. Such a detailed exploration of the CGA process and the clinical skills necessary to deliver it, should be used to inform future multicenter studies and the development and implementation of perioperative services for older patients.
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Affiliation(s)
- Rihan Shahab
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nicola Lochrie
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ian K Moppett
- Department of Anesthesia, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Anesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Prokar Dasgupta
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Judith S L Partridge
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Jugdeep K Dhesi
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, United Kingdom.
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14
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Partridge JSL, Ryan J, Dhesi JK, Barker C, Bates L, Bell R, Bryden D, Carter S, Clegg A, Conroy S, Cowley A, Curtis A, Diedo B, Eardley W, Evley R, Hare S, Hopper A, Humphry N, Kanga K, Kilvington B, Lees NP, McDonald D, McGarrity L, McNally S, Meilak C, Mudford L, Nolan C, Pearce L, Price A, Proffitt A, Romano V, Rose S, Selwyn D, Shackles D, Syddall E, Taylor D, Tinsley S, Vardy E, Youde J. New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary. Age Ageing 2022; 51:6847803. [PMID: 36436009 DOI: 10.1093/ageing/afac237] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/02/2022] [Indexed: 11/28/2022] Open
Abstract
Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.
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Affiliation(s)
- Judith S L Partridge
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
| | - Jack Ryan
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep K Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
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15
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Partridge JSL, Moonesinghe SR, Lees N, Dhesi JK. Perioperative care for older people. Age Ageing 2022; 51:6678855. [PMID: 36040439 DOI: 10.1093/ageing/afac194] [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: 07/06/2022] [Indexed: 01/25/2023] Open
Abstract
Increasing numbers of older people are undergoing surgery with benefits including symptom relief and extended longevity. Despite these benefits, older people are more likely than younger patients to experience postoperative complications, which are predominantly medical as opposed to surgical. Comprehensive Geriatric Assessment and optimisation offers a systematic approach to risk assessment and risk modification in the perioperative period. Clinical evidence shows that Comprehensive Geriatric Assessment and optimisation reduces postoperative medical complications and is cost effective in the perioperative setting. These benefits have been observed in patients undergoing elective and emergency surgery. Challenges in the implementation of perioperative Comprehensive Geriatric Assessment and optimisation services are acknowledged. These include the necessary involvement of a wide stakeholder group, limited available geriatric medicine workforce and ensuring fidelity to Comprehensive Geriatric Assessment methodology with adaptation to the local context. Addressing these challenges needs a cross-specialty, interdisciplinary approach underpinned by evidence-based medicine and implementation science with upskilling to facilitate innovative use of the extended workforce. Future delivery of quality patient-centred perioperative care requires proactive engagement with national audit, collaborative guidelines and establishment of networks to share best practice.
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Affiliation(s)
- Judith S L Partridge
- Consultant Geriatrician, Perioperative Medicine for Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Honorary Senior Lecturer, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - S Ramani Moonesinghe
- Professor of Perioperative Medicine, University College London (UCL), London, UK
- Consultant in Anaesthesia, Department of Critical and Perioperative Care, University College Hospitals, London, UK
| | - Nicholas Lees
- Consultant General & Colorectal Surgeon, Salford Royal, Northern Care Alliance NHS Foundation Trust, UK
| | - Jugdeep K Dhesi
- Consultant Geriatrician, Perioperative Medicine for Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Honorary Professor, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Honorary Associate Professor, Division of Surgery and Interventional Science, University College London, London, UK
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16
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Zuccarino S, Monacelli F, Antognoli R, Nencioni A, Monzani F, Ferrè F, Seghieri C, Antonelli Incalzi R. Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review. Cancers (Basel) 2022; 14:cancers14133235. [PMID: 35805005 PMCID: PMC9265029 DOI: 10.3390/cancers14133235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary The Comprehensive Geriatric Assessment is a multidimensional and multidisciplinary evaluation designed for elderly patients with the goal of structuring tailored care and follow-up. Despite the known benefits of this approach, the Comprehensive Geriatric Assessment is not universally applied to elderly cancer patients due to economic and practical barriers. This narrative review aims to investigate the cost-effectiveness of the Comprehensive Geriatric Assessment adopted in geriatric oncology. The results revealed a lack of research on the topic, but recurrent cost-saving effects of this approach in geriatric oncology settings were highlighted—suggesting a positive cost-effectiveness ratio. Further structured research with comprehensive economic evaluations is needed to confirm these findings. Abstract The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.
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Affiliation(s)
- Sara Zuccarino
- Management and Health Laboratory, Institute of Management–Department Embeds, Sant’Anna School of Advanced Studies, 56127 Pisa, Italy; (F.F.); (C.S.)
- Correspondence: (S.Z.); (F.M.); (R.A.I.)
| | - Fiammetta Monacelli
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, 16132 Genoa, Italy; (F.M.); (A.N.)
- IRCSS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Rachele Antognoli
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, 56126 Pisa, Italy;
| | - Alessio Nencioni
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, 16132 Genoa, Italy; (F.M.); (A.N.)
- IRCSS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, 56126 Pisa, Italy;
- Correspondence: (S.Z.); (F.M.); (R.A.I.)
| | - Francesca Ferrè
- Management and Health Laboratory, Institute of Management–Department Embeds, Sant’Anna School of Advanced Studies, 56127 Pisa, Italy; (F.F.); (C.S.)
| | - Chiara Seghieri
- Management and Health Laboratory, Institute of Management–Department Embeds, Sant’Anna School of Advanced Studies, 56127 Pisa, Italy; (F.F.); (C.S.)
| | - Raffaele Antonelli Incalzi
- Unit of Geriatrics, Department of Medicine, Campus Bio-Medico di Roma University, 00128 Rome, Italy
- Correspondence: (S.Z.); (F.M.); (R.A.I.)
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17
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Matthews L, Levett DZH, Grocott MPW. Perioperative Risk Stratification and Modification. Anesthesiol Clin 2022; 40:e1-e23. [PMID: 35595387 DOI: 10.1016/j.anclin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.
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Affiliation(s)
- Lewis Matthews
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom.
| | - Denny Z H Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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18
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Giannotti C, Massobrio A, Carmisciano L, Signori A, Napolitano A, Pertile D, Soriero D, Muzyka M, Tagliafico L, Casabella A, Cea M, Caffa I, Ballestrero A, Murialdo R, Laudisio A, Incalzi RA, Scabini S, Monacelli F, Nencioni A. Effect of Geriatric Comanagement in Older Patients Undergoing Surgery for Gastrointestinal Cancer: A Retrospective, Before-and-After Study. J Am Med Dir Assoc 2022; 23:1868.e9-1868.e16. [DOI: 10.1016/j.jamda.2022.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
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19
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Pritchard ALM, Chin KL, Story DA, Smart P, Jones DA, See E, Nazareth JM. The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery. Aust Crit Care 2022:S1036-7314(22)00059-5. [DOI: 10.1016/j.aucc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022] Open
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20
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Thillainadesan J, Hilmer SN, Fleury AM, Naganathan V. New horizons in the perioperative care of older adults. Age Ageing 2022; 51:6520523. [PMID: 35134849 DOI: 10.1093/ageing/afab245] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Indexed: 12/18/2022] Open
Abstract
Older adults undergoing surgery have high perioperative morbidity and mortality. Age-related physiological changes and prevalence of geriatric syndromes such as frailty increase the risk of adverse postoperative outcomes. Geriatricians utilise comprehensive geriatric assessment (CGA) and management to identify and manage geriatric syndromes, and deliver patient-centred perioperative care. Perioperative models of CGA are established for older patients undergoing hip fracture surgery. Recent trials support the benefits of perioperative models of CGA for non-orthopaedic surgery, and have influenced current care recommendations for older surgical patients. Areas for further action include addressing the implementation gap between recommended evidence-based perioperative care and routine perioperative care, evaluating the clinical and cost-effectiveness of perioperative models of CGA for patients living with frailty, and embedding routine use of patient-reported outcome measures to inform quality improvement.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, Australia
- Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia
| | - Sarah N Hilmer
- Department of Aged Care, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Aisling M Fleury
- Perioperative Medicine Unit, Division of Surgery, Logan Hospital, Logan, Queensland, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, Australia
- Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia
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21
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Parks R, Cheung KL. Challenges in Geriatric Oncology—A Surgeon’s Perspective. Curr Oncol 2022; 29:659-674. [PMID: 35200558 PMCID: PMC8870873 DOI: 10.3390/curroncol29020058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 01/29/2023] Open
Abstract
As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient’s vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians—a shared care approach between surgical oncologists and geriatricians is required.
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Affiliation(s)
- Ruth Parks
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham NG7 2RD, UK;
- School of Medicine, Royal Derby Hospital Centre, Uttoxeter Road, University of Nottingham, Derby DE22 3DT, UK
- Correspondence: ; Tel.: +44-(0)-1332-724881
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22
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Stubbs DJ, Davies BM, Menon DK. Chronic subdural haematoma: the role of peri‐operative medicine in a common form of reversible brain injury. Anaesthesia 2022; 77 Suppl 1:21-33. [DOI: 10.1111/anae.15583] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 01/08/2023]
Affiliation(s)
- D. J. Stubbs
- University Division of Anaesthesia Department of Medicine Addenbrooke’s Hospital Cambridge UK
| | - B. M. Davies
- Department of Academic Neurosurgery Addenbrooke’s Hospital Cambridge UK
| | - D. K. Menon
- University Division of Anaesthesia Department of Medicine Addenbrooke’s Hospital Cambridge UK
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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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de Las Casas R, Meilak C, Whittle A, Partridge J, Adamek J, Sadler E, Sevdalis N, Dhesi J. Establishing a perioperative medicine for older people undergoing surgery service for general surgical patients at a district general hospital. Clin Med (Lond) 2021; 21:e608-e614. [PMID: 34862220 DOI: 10.7861/clinmed.2021-0356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is growing recognition of the need for perioperative medicine services for older surgical patients. Comprehensive geriatric assessment and optimisation methodology has been successfully used to improve perioperative outcomes at tertiary centres. This paper describes translation of an established model of geriatrician-led perioperative care to a district general hospital (DGH) setting. METHODS A mixed methods quality improvement programme was used and included stakeholder co-design, identification of core components, definition of mechanisms for change, and measurement of impact through qualitative and quantitative approaches. RESULTS Within 18 months, a substantive perioperative service for older people was established at a DGH, funded by the surgical directorate. Key outcomes included reduction in length of stay and 30-day readmission and positive staff and patient experience. DISCUSSION This study is in keeping with improvement science literature demonstrating the importance of a mixed-methods approach in translating an evidenced-based intervention into another setting, maintaining fidelity and replicating results.
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Affiliation(s)
| | | | | | - Judith Partridge
- Guy's and St Thomas' NHS Foundation Trust, London and honorary senior lecturer, King's College London, London, UK
| | | | - Euan Sadler
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK, honorary reader, King's College London, London, UK, and honorary associate professor, University College London, London, UK
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Partridge JSL, Healey A, Modarai B, Harari D, Martin FC, Dhesi JK. Preoperative comprehensive geriatric assessment and optimisation prior to elective arterial vascular surgery: a health economic analysis. Age Ageing 2021; 50:1770-1777. [PMID: 34120179 DOI: 10.1093/ageing/afab094] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND increasing numbers of older people are undergoing vascular surgery. Preoperative comprehensive geriatric assessment and optimisation (CGA) reduces postoperative complications and length of hospital stay. Establishing CGA-based perioperative services requires health economic evaluation prior to implementation. Through a modelling-based economic evaluation, using data from a single site clinical trial, this study evaluates whether CGA is a cost-effective alternative to standard preoperative assessment for older patients undergoing elective arterial surgery. METHODS an economic evaluation, using decision-analytic modelling, comparing preoperative CGA and optimisation with standard preoperative care, was undertaken in older patients undergoing elective arterial surgery. The incremental net health benefit of CGA, expressed in terms of quality-adjusted life-years (QALYs), was used to evaluate cost-effectiveness. RESULTS CGA is a cost-effective substitute for standard preoperative care in elective arterial surgery across a range of cost-effectiveness threshold values. An incremental net benefit of 0.58 QALYs at a cost-effectiveness threshold of £30k, 0.60 QALYs at a threshold of £20k and 0.63 QALYs at a threshold of £13k was observed. Mean total pre- and postoperative health care utilisation costs were estimated to be £1,165 lower for CGA patients largely accounted for by reduced postoperative bed day utilisation. CONCLUSION this study demonstrates a likely health economic benefit in addition to the previously described clinical benefit of employing CGA methodology in the preoperative setting in older patients undergoing arterial surgery. Further evaluation should examine whether CGA-based perioperative services can be effectively implemented and achieve the same clinical and health economic outcomes at scale.
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Affiliation(s)
- Judith S L Partridge
- Department of Ageing and Health, Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Andrew Healey
- Centre for Implementation Science and King's Health Economics, King's College London, London, UK
| | - Bijan Modarai
- School of Biomedical Engineering & Imaging Sciences, Rayne Institute, King's College London, London, UK
- Academic department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Danielle Harari
- Department of Ageing and Health, Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Finbarr C Martin
- School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jugdeep K Dhesi
- Department of Ageing and Health, Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Population Health & Environmental Sciences, 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
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Kanga K, Dickson E, Van Huellen H, De Las Casas R, Cadd M, Stanworth SJ, Grant-Casey J, Sugavanam A. Under-recognised burden of postoperative anaemia in patients undergoing emergency abdominal surgery in the UK. Br J Anaesth 2021; 127:e105-e108. [PMID: 34330412 DOI: 10.1016/j.bja.2021.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Kate Kanga
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | - Edward Dickson
- Nottingham Digestive Diseases Centre Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Hans Van Huellen
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ruth De Las Casas
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Matthew Cadd
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John Grant-Casey
- National Comparative Audit of Blood Transfusion, NHS Blood and Transplant, Oxford, UK
| | - Anita Sugavanam
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Colorectal Cancer in Elderly Patients with Surgical Indication: State of the Art, Current Management, Role of Frailty and Benefits of a Geriatric Liaison. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116072. [PMID: 34199923 PMCID: PMC8200127 DOI: 10.3390/ijerph18116072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 12/24/2022]
Abstract
Six out of every 10 new colorectal cancer (CRC) diagnoses are in people over 65 years of age. Current standardized surgical approaches have proved to be tolerable on the elderly population, although post-operative complications are more frequent than in the younger CRC population. Frailty is common in elderly CRC patients with surgical indication, and it appears to be also associated with an increase of post-operative complications. Fast-track pathways have been developed to assure and adequate post-operative recovery, but comprehensive geriatric assessments (CGA) are still rare among the preoperative evaluation of elderly CRC patients. This review provides a thorough study of the effects that a CGA assessment and a geriatric intervention have in the prognosis of CRC elderly patients with surgical indication.
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Ramírez-Martín R, Menéndez Colino R, Déniz González V, Gazo Martínez JA, Marijuán Martín JL, González-Montalvo JI. [The efficiency of «Cross-speciality Geriatrics» in the co-management of patients older than 80 years admitted to the General Surgery Service. Economic results]. Rev Esp Geriatr Gerontol 2021; 56:87-90. [PMID: 33518381 DOI: 10.1016/j.regg.2020.12.004] [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: 10/19/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To determine the efficiency of «Cross-speciality Geriatrics» program in patients older than 80 years admitted to the Colorectal Pathology Unit of a General Surgery Department. MATERIAL AND METHODS A «before-after» study was conducted. The initial period (usual treatment for General Surgery) included patients admitted from 1st January to 31st August 2018, and the subsequent period (with support from geriatrics) from 1st January to 31st December 2019. Two types of patients were studied: Type 1, who were admitted to the Emergency Department, and Type 2, programmed admissions for colorectal cancer intervention. The Geriatrics intervention consisted of daily monitoring in the ward, collaboration in clinical management, and discharge planning. Furthermore, in Type 2 patients, a previous visit was made in the clinic, which included the detection and approach of frailty and pre-habilitation for surgery. RESULTS A total of 175 patients were included, of whom 53 were treated by General Surgery and 122 with the co-management of geriatrics. The mean age was 84.9 years (SD 4.8). In the period with the Cross-speciality Geriatrics program, the mean stay was reduced by 10.6 days (39%), and 8.5 days (44%) in types 1 and 2, respectively (P < .01). This led to a decrease in bed occupancy (3.3 beds/day) and a cost reduction (1,215,970 € / year). CONCLUSIONS The support of Cross-speciality Geriatrics in patients older than 80 years admitted to General Surgery is an efficient care model. These data support its implementation in hospitals where this care line has not yet been developed.
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Affiliation(s)
| | - Rocío Menéndez Colino
- Servicio de Geriatría. Hospital Universitario La Paz, Madrid, España; Facultad de Medicina. Universidad Autónoma de Madrid, Madrid, España
| | | | | | | | - Juan Ignacio González-Montalvo
- Servicio de Geriatría. Hospital Universitario La Paz, Madrid, España; Facultad de Medicina. Universidad Autónoma de Madrid, Madrid, España
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Halvachizadeh S, Gröbli L, Berk T, Jensen KO, Hierholzer C, Bischoff-Ferrari HA, Pfeifer R, Pape HC. The effect of geriatric comanagement (GC) in geriatric trauma patients treated in a level 1 trauma setting: A comparison of data before and after the implementation of a certified geriatric trauma center. PLoS One 2021; 16:e0244554. [PMID: 33428650 PMCID: PMC7799827 DOI: 10.1371/journal.pone.0244554] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/13/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Improvements in life expectancy imply that an increase of geriatric trauma patients occurs. These patients require special attention due to their multiple comorbidity issues. The aim of this study was to assess the impact of the implementation of geriatric comanagement (GC) on the allocation and clinical outcome of geriatric trauma patients. METHODS This observational cohort study aims to compare the demographic development and the clinical outcome in geriatric trauma patients (aged 70 years and older) before and after implementation of a certified geriatric trauma center (GC). Geriatric trauma patients admitted between January 1, 2010 and December 31, 2010 were stratified to group pre-GC and admissions between January 1, 2018 and December 31, 2018 to Group post-GC. We excluded patients requiring end-of-life treatment and those who died within 24 h or due to severe traumatic brain injury. Outcome parameters included demographic changes, medical complexity (measured by American Society of Anaesthesiology Score (ASA) and Charlson Comorbidity Index (CCI)), in-hospital mortality and length of hospitalization. RESULTS This study includes 626 patients in Group pre-GC (mean age 80.3 ± 6.7 years) and 841 patients in Group post-GC (mean age 81.1 ± 7.3 years). Group pre-GC included 244 (39.0%) males, group post-GC included 361 (42.9%) males. The mean CCI was 4.7 (± 1.8) points in pre-GC and 5.1 (± 2.0) points in post-GC (p <0.001). In Group pre-GC, 100 patients (16.0%) were stratified as ASA 1 compared with 47 patients (5.6%) in Group post-GC (p <0.001). Group pre-GC had significantly less patients stratified as ASA 3 or higher (n = 235, 37.5%) compared with Group post-GC (n = 389, 46.3%, p <0.001). Length of stay (LOS) decreased significantly from 10.4 (± 20.3) days in Group pre-GC to 7.9 (±22.9) days in Group post-GC (p = 0.011). The 30-day mortality rate was comparable amongst these groups (pre-GC 8.8% vs. post-GC 8.9%). CONCLUSION This study appears to support the implementation of a geriatric trauma center, as certain improvements in the patient care were found: Despite a higher CCI and a higher number of patients with higher ASA classifications, Hospital LOS, complication rates and mortality did were not increased after implementation of the CG. The increase in the case numbers supports the fact that a higher degree of specialization leads to a response by admitting physicians, as it exceeded the expectable trend of demographic ageing. We feel that a larger data base, hopefully in a multi center set up should be undertaken to verify these results.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University Hospital Zurich, Zurich, Switzerland
- * E-mail:
| | | | - Till Berk
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Christian Hierholzer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
| | - Heike A. Bischoff-Ferrari
- Department of Geriatric Medicine, University Hospital Zurich, Zurich, Switzerland
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Waid City Hospital Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University Hospital Zurich, Zurich, Switzerland
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Mitchell E, Coary R, White P, Farrow E, Crees A, Beedham W, Devine M, Winterborn R, Shipway D. Daily Medical Liaison is Associated with Reduced Length of Stay and Complications in Selected Patients Admitted to a Regional Vascular Surgery Service. Geriatrics (Basel) 2020; 5:E78. [PMID: 33080857 PMCID: PMC7709670 DOI: 10.3390/geriatrics5040078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 12/02/2022] Open
Abstract
Older adults undergoing vascular surgery are particularly vulnerable to adverse outcomes by virtue of their vascular risk factors and medical comorbidities. This study aimed to determine the impact of daily medical liaison for patients aged 65 years and older admitted to a regional vascular surgery centre. This was a descriptive before-and-after study concerning 375 patients. The primary outcome measure was length of stay (LOS). Following intervention, we identified a reduction in mean LOS in the sample from 10.75 to 7.95 days (p = 0.635, 95% Confidence Interval [CI] 0-5 days) with a statistically significant reduction in mean LOS for "stranded" patients admitted for more than seven days (mean 7.84 days reduction, p = 0.025, 95% CI for mean difference, 1.5 to 14 days). These patients did not display elevated 30-day readmission rates (12/60 to 8/72, p = 0.156, 95% CI -3% to 21%). A non-significant reduction in postoperative complications was seen in all patients in the post-intervention cohort (1.09 to 0.86 per person, p = 0.181, 95% CI -0.11 to 0.56), reaching statistical significance in emergency vascular admissions (1.81 to 0.97 complications per person, p = 0.01, mean difference = 0.84, 95% CI 0.21-1.46). This study demonstrated reduced LOS and complications in selected older patients admitted under vascular surgery after the introduction of a daily medical liaison model. These data are amongst the first to reproduce randomised controlled trial findings in a non-trial setting. Subgroup analysis indicates that patients admitted with acute pathology and those with long LOS may benefit most from medical liaison where resources are finite.
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Affiliation(s)
- Emma Mitchell
- Department of Medicine for Older People, North Bristol NHS Foundation Trust, Bristol BS10 5NB, UK; (E.M.); (E.F.); (A.C.); (M.D.)
| | - Roisin Coary
- Department of Medicine for the Elderly, St James’s Hospital, P.O. Box 580 Dublin, Ireland;
| | - Paul White
- Applied Statistics Group, Faculty of Environment and Technology, University of the West of England, Bristol BS16 1QY, UK;
| | - Emily Farrow
- Department of Medicine for Older People, North Bristol NHS Foundation Trust, Bristol BS10 5NB, UK; (E.M.); (E.F.); (A.C.); (M.D.)
| | - Amy Crees
- Department of Medicine for Older People, North Bristol NHS Foundation Trust, Bristol BS10 5NB, UK; (E.M.); (E.F.); (A.C.); (M.D.)
| | - William Beedham
- Birmingham Medical School, University of Birmingham, Birmingham B15 2TT, UK;
| | - Mark Devine
- Department of Medicine for Older People, North Bristol NHS Foundation Trust, Bristol BS10 5NB, UK; (E.M.); (E.F.); (A.C.); (M.D.)
| | - Rebecca Winterborn
- Department of Vascular Surgery, North Bristol NHS Foundation Trust, Bristol BS10 5NB, UK;
| | - David Shipway
- Department of Medicine for Older People, North Bristol NHS Foundation Trust, Bristol BS10 5NB, UK; (E.M.); (E.F.); (A.C.); (M.D.)
- Honorary Senior Clinical Lecturer, Department of Population Health Sciences, University of Bristol, Bristol BS8 1QU, UK
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Owens GL, Sivalingam V, Abdelrahman M, Beirne JP, Blake D, Collins A, Davies R, Dilley J, Farquharson M, Frimpong D, Gomes N, Hawco S, Ilenkovan N, Jones E, Jones SEF, Khan T, Leung E, Otify M, Parnell L, Rimmer MP, Ryan N, Sanderson P, Stocker L, Wilkinson M, Wong S, Bharathan R, Wan YLL. Are trainees working in obstetrics and gynecology confident and competent in the care of frail gynecological oncology patients? Int J Gynecol Cancer 2020; 30:1959-1965. [PMID: 33046571 DOI: 10.1136/ijgc-2020-001834] [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: 07/14/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Older patients undergoing cancer surgery are at increased risk of post-operative complications, prolonged hospital stay, and mortality. Identification of frailty can help predict patients at high risk of peri-operative complications and allow a collaborative, multidisciplinary team approach to their care. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynecology regarding identification and management of peri-operative issues encountered in frail gynecological oncology patients. METHODS A web-based survey was distributed via the Audit and Research in Gynaecological Oncology (ARGO) collaborative and UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) . The survey on the management of frail peri-operative patients was disseminated to doctors-in-training (trainees) working in obstetrics and gynecology in the United Kingdom (UK) and Ireland. Specialty (ST1-7), subspecialty, and general practice trainees, non-training grade doctors, and foundation year doctors currently working in obstetrics and gynecology were eligible. Consultants were excluded. Study data were collected using REDCAP software hosted at the University of Manchester. Responses were collected over a 6-week period between January and February 2020. RESULTS Of the 666 trainees who participated, 67% (425/666) reported inadequate training in peri-operative management of frail patients. Validated frailty assessment tools were used by only 9% (59/638) of trainees and less than 1% (4/613) were able to correctly identify all the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority of trainees (76.5%, 448/586) correctly answered a series of questions relating to mental capacity; however, only 6% (36/606) were able to correctly identify all three diagnostic features of delirium. A total of 87% (495/571) of trainees supported closer collaboration with geriatricians and a multidisciplinary approach. CONCLUSIONS Obstetrics and gynecology trainees reported inadequate training in the peri-operative care of frail gynecological oncology patients, and overwhelmingly favored input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the peri-operative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish obstetrics and gynecology curriculum.
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Affiliation(s)
- Gemma Louise Owens
- Division of Cancer Sciences, School of Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK .,Obstetrics and Gynaecology, Sharoe Green Unit, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Vanitha Sivalingam
- Division of Cancer Sciences, School of Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | | | - James P Beirne
- Patrick J Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK.,Northern Ireland Gynaecological Cancer Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Dominic Blake
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Anna Collins
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Rhianna Davies
- Obstetrics and Gynaecology, Addenbrooke's Hospital, Cambridge, UK
| | - James Dilley
- Gynaecological Oncology, Barts and The London NHS Trust, London, UK
| | | | - Diana Frimpong
- East Gynaecological Oncology Centre, Queen Elizabeth the Queen Mother Hospital, Margate, UK
| | - Nana Gomes
- Gynaecological Oncology, St George's Hospital, London, UK
| | - Sarah Hawco
- Obstetrics and Gynaecology, Ninewells Hospital, Dundee, UK
| | - Narthana Ilenkovan
- Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Eleanor Jones
- Division of Cancer Sciences, School of Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | | | - Tabassum Khan
- Gynaecological Oncology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elaine Leung
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Mohamed Otify
- Gynaecological Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Laura Parnell
- Obstetrics and Gynaecology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Michael P Rimmer
- MRC Centre for Reproductive Health, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Neil Ryan
- Academic Centre for Women's Health, University of Bristol, Bristol, UK
| | - Peter Sanderson
- Gynaecological Oncology, Simpson Centre for Reproductive Health, Edinburgh, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Linden Stocker
- Academic Unit of Human Development and Health, University of Southampton, Southampton, UK
| | - Michael Wilkinson
- Gynaecological Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siewchee Wong
- Obstetrics and Gynaecology, Lincoln County Hospital, Lincoln, UK
| | - Rasiah Bharathan
- Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Yee-Loi Louise Wan
- Division of Cancer Sciences, School of Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Koizia LJ, Dani M, Sritharan G, Peck G, Fertleman MB. Collaborative working on a 7-day rota reduces length of stay. Future Healthc J 2020; 7:e84. [DOI: 10.7861/fhj.2020-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Aitken RM, Partridge JSL, Oliver CM, Murray D, Hare S, Lockwood S, Beckley-Hoelscher N, Dhesi JK. Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1-4. Age Ageing 2020; 49:656-663. [PMID: 32484859 DOI: 10.1093/ageing/afaa075] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014-2017) since NELA was established. METHODS patient-level data were populated from the NELA data set years 1-4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. RESULTS in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1-4 (8.5 to 16.5%, P < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35-0.42, P < 0.001; 90-day OR 0.6, CI 0.56-0.65, P < 0.001). CONCLUSIONS older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.
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Affiliation(s)
- Rachel M Aitken
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
| | - Judith S L Partridge
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Charles Matthew Oliver
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Health Systems Research, UCL Division of Targeted Intervention, London, UK
| | - Dave Murray
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Sarah Hare
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - Sonia Lockwood
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- General Surgery Unit, Bradford Royal Infirmary, Bradford Teaching Hospitals, Bradford, UK
| | | | - Jugdeep K Dhesi
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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Partridge JSL, Aitken RM, Dhesi JK. Perioperative medicine for older people: Learning across continents. Australas J Ageing 2020; 38:228-230. [PMID: 31797515 DOI: 10.1111/ajag.12723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/06/2019] [Accepted: 08/22/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Judith Stephanie Louise Partridge
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Margaret Aitken
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Aged Care, Caulfield Hospital, Alfred Health, Melbourne, Vic., Australia
| | - Jugdeep Kaur Dhesi
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
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González-Montalvo JI, Ramírez-Martín R, Menéndez Colino R, Alarcón T, Tarazona-Santabalbina FJ, Martínez-Velilla N, Vidán MT, Pi-Figueras Valls M, Formiga F, Rodríguez Couso M, Hormigo Sánchez AI, Vilches-Moraga A, Rodríguez-Pascual C, Gutiérrez Rodríguez J, Gómez-Pavón J, Sáez López P, Bermejo Boixareu C, Serra Rexach JA, Martínez Peromingo J, Sánchez Castellano C, González Guerrero JL, Martín-Sánchez FJ. [Cross-speciality geriatrics: A health-care challenge for the 21st century]. Rev Esp Geriatr Gerontol 2020; 55:84-97. [PMID: 31870507 DOI: 10.1016/j.regg.2019.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 06/10/2023]
Abstract
Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.
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Affiliation(s)
- Juan Ignacio González-Montalvo
- Servicio de Geriatría, Hospital Universitario La Paz, IdiPAZ, Madrid, España; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España.
| | | | | | - Teresa Alarcón
- Servicio de Geriatría, Hospital Universitario La Paz, IdiPAZ, Madrid, España; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
| | | | - Nicolás Martínez-Velilla
- Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), IDISNA, Pamplona, España
| | - María Teresa Vidán
- Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, IiSGM, Facultad de Medicina, Universidad Complutense de Madrid, CIBERFES, Madrid, España
| | | | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, IDIBELL, Hospital Universitario de Bellvitge, ĹHospitalet de Llobregat, Barcelona, España
| | | | - Ana Isabel Hormigo Sánchez
- Servicio de Geriatría, Hospital Universitario Fundación Jiménez Díaz, Madrid, España; Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
| | - Arturo Vilches-Moraga
- Servicio de Geriatría, Salford Royal NHS Foundation Trust, Facultad de Medicina, Universidad de Manchester, Manchester, Inglaterra
| | | | - José Gutiérrez Rodríguez
- Área de Gestión Clínica de Geriatría, Hospital Monte Naranco, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, España
| | - Javier Gómez-Pavón
- Servicio de Geriatría, Hospital Central de la Cruz Roja San José y Santa Adela, Facultad de Medicina, Universidad Alfonso X el Sabio, Madrid, España
| | - Pilar Sáez López
- Unidad de Geriatría, Hospital Universitario Fundación de Alcorcón, IdiPAZ, Alcorcón, Madrid, España
| | | | - José Antonio Serra Rexach
- Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, IiSGM, Facultad de Medicina, Universidad Complutense de Madrid, CIBERFES, Madrid, España
| | | | | | - José Luis González Guerrero
- Servicio de Geriatría, Hospital San Pedro de Alcántara, Complejo Hospitalario Universitario de Cáceres, Cáceres, España
| | - Francisco Javier Martín-Sánchez
- Servicio de Urgencias, Hospital Universitario Clínico San Carlos, IdiSSC, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
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Khan KA, Subramanian T, Richters M, Mubarik A, Saad Abdalla Al-Zawi A, Thorn CC, Chalstrey S, Gunasekera S. Working Collaboratively: Outcomes of Geriatrician Input in Older Patients Undergoing Emergency Laparotomy in a District General Hospital. Cureus 2020; 12:e7069. [PMID: 32104643 PMCID: PMC7039363 DOI: 10.7759/cureus.7069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
With the increasing median age of survival in the UK, there is an increased burden on the provision of medical and surgical care to the population. The 2010 National Confidential Enquiry into Patient Outcome and Death report, "An Age Old Problem," emphasizes the early involvement of surgical and geriatric consultant input to improve perioperative care in older patients. This study describes the development of a Geriatric Surgical Liaison Service aimed at providing consultant-led geriatrician support to improve the outcomes of older patients undergoing Emergency Laparotomy (EL). The primary outcome is the reduction in length of stay (LOS) compared to baseline data prior to geriatrician involvement. The service was designed to include one clinical session involving a consultant geriatrician and two and a half days with a junior doctor in a week. Data was collected prospectively from February 2018 till July 2018 for surgical patients aged ≥ 70 years, who underwent EL, had an inpatient stay of more than seven days, and who were diagnosed with delirium or incurred inpatient falls (intervention group). Baseline data, prior to geriatrician involvement, were collected retrospectively for EL patients aged ≥ 70 years from December 2015 until May 2016. Length of stay and 30-day mortality were also compared between the two cohorts undergoing EL. A total of 69 patients were included in the intervention group; 45 patients underwent EL and their mean LOS was 17.5 days, which was reduced from 22.5 days prior to geriatrician involvement (n=57). There was no difference in median length of stay and 30-day mortality between the retrospective baseline group and the intervention groups. In the intervention group, 8.5% of patients had a new medical diagnosis and 26.8% of patients were offered follow-ups. Although statistically not significant (p=0.40), a shorter stay in hospital by five days can potentially have a positive impact on patient outcomes by reducing psychosocial, cognitive, and functional deconditioning. This would also improve patient flow, release capacity, and waiting times and would be of benefit to the financially strained National Health Service (NHS). Overall, our study suggests that a collaborative, consultant-led geriatric service can improve the management of older surgical patients by potentially reducing length of stay, identifying high-risk patients, and facilitating early and appropriate specialty input alongside adequate and required outpatient follow-up.
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Affiliation(s)
- Kashuf A Khan
- General Surgery, Royal Shrewsbury and Telford National Health Service (NHS) Trust, Shrewsbury, GBR
| | - Thejasvi Subramanian
- General Surgery, Good Hope Hospital, University Hospitals Birmingham, Birmingham, GBR
| | - Megan Richters
- Internal Medicine, Great Western Hospital National Health Service (NHS) Foundation Trust, Swindon, GBR
| | - Ayesha Mubarik
- Family Medicine, Whiston Hospital, St Helens and Knowsley Teaching Hospitals National Health Service (NHS) Trust, Rochdale, GBR
| | | | - Christopher C Thorn
- General Surgery, Great Western Hospital National Health Service (NHS) Foundation Trust, Swindon, GBR
| | - Susan Chalstrey
- Otolaryngology, Great Western Hospital National Health Service (NHS) Foundation Trust, Swindon, GBR
| | - Savithri Gunasekera
- Geriatrics, Frimley Health National Health Service (NHS) Foundation Trust, Frimley, GBR
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Impact of geriatric co-management programmes on outcomes in older surgical patients: update of recent evidence. Curr Opin Anaesthesiol 2020; 33:114-121. [DOI: 10.1097/aco.0000000000000815] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Santhirapala R, Partridge J, MacEwen CJ. The older surgical patient – to operate or not? A state of the art review. Anaesthesia 2020; 75 Suppl 1:e46-e53. [DOI: 10.1111/anae.14910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 12/17/2022]
Affiliation(s)
- R. Santhirapala
- Department of Theatres, Anaesthesia and Peri‐operative Medicine Guy's and St Thomas’ NHS Foundation Trust London UK
- Division of Surgery and Interventional Science University College London London UK
- Academy of Medical Royal Colleges London UK
| | - J. Partridge
- Peri‐operative medicine for Older People undergoing Surgery (POPS) Guy's and St Thomas’ NHS Foundation TrustLondon UK
- Division of Primary Care and Public Health Sciences Faculty of Life Sciences and Medicine King's College London London UK
| | - C. J. MacEwen
- Academy of Medical Royal Colleges London UK
- Department of Ophthalmology University of Dundee UK
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39
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Dean HF, Carter F, Francis NK. Modern perioperative medicine - past, present, and future. Innov Surg Sci 2019; 4:123-131. [PMID: 33977121 PMCID: PMC8059350 DOI: 10.1515/iss-2019-0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022] Open
Abstract
Modern perioperative medicine has dramatically altered the care for patients undergoing major surgery. Anaesthetic and surgical practice has been directed at mitigating the surgical stress response and reducing physiological insult. The development of standardised enhanced recovery programmes combined with minimally invasive surgical techniques has lead to reduction in length of stay, morbidity, costs, and improved outcomes. The enhanced recovery after surgery (ERAS) society and its national chapters provide a means for sharing best practice in this field and developing evidence based guidelines. Research has highlighted persisting challenges with compliance as well as ensuring the effectiveness and sustainability of ERAS. There is also a growing need for increasingly personalised care programmes as well as complex geriatric assessment of frailer patients. Continuous collection of outcome and process data combined with machine learning, offers a potentially powerful solution to delivering bespoke care pathways and optimising individual management. Long-term data from ERAS programmes remain scarce and further evaluation of functional recovery and quality of life is required.
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Affiliation(s)
- Harry F. Dean
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - Fiona Carter
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil, UK
| | - Nader K. Francis
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil BA21 4AT, UK
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil BA20 2RH, UK
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK, Tel.: (01935) 384244
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Rogerson A, Partridge JSL, Dhesi JK. Perioperative Medicine for Older People. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2019. [DOI: 10.47102/annals-acadmedsg.v48n11p376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Global demographic changes have resulted in an older, frailer surgical population with significant multimorbidity causing higher frequency of adverse postoperative outcomes. The need for restructuring of perioperative care pathways to address this issue has been recognised. Comprehensive geriatric assessment (CGA) and optimisation are emerging as innovative perioperative pathways. This paper describes one centre’s approach in applying CGA in the surgical setting and presents the evidence in support of this. Similar models are being established in Singapore in hip fracture, colorectal and vascular populations. The challenges in the widespread adoption of such models of care are similar across settings. The global nature of translation is also discussed in this paper.
Key words: Comprehensive geriatric assessment, Geriatrician-led multidisciplinary team, Optimisation
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Affiliation(s)
| | - Judith SL Partridge
- Proactive Care of Older People Undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, United Kingdom
| | - Jugdeep K Dhesi
- Proactive Care of Older People Undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, United Kingdom
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Dhesi J, Moonesinghe SR, Partridge J. Comprehensive Geriatric Assessment in the perioperative setting; where next? Age Ageing 2019; 48:624-627. [PMID: 31147709 DOI: 10.1093/ageing/afz069] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Indexed: 11/13/2022] Open
Abstract
Comprehensive Geriatric Assessment (CGA) is being employed in the perioperative setting to improve outcomes for older surgical patients. Traditionally CGA is delivered by a geriatrician led multidisciplinary team but with the acknowledged workforce challenges in geriatric medicine, it has been suggested that non-geriatricians may be able to deliver CGA. HOW-CGA developed a toolkit to facilitate the delivery of CGA by non-geriatricians in the perioperative setting. Across two hospital sites uptake and implementation of this toolkit was limited by a potential lack of face validity, behavioural and cultural barriers and an acknowledgement that geriatric medicine expertise is key to CGA and optimisation. In-keeping with this finding there has been an observed expansion in geriatrician led CGA services for older surgical patients in the UK. In order to demonstrate the effectiveness of perioperative CGA services, implementation science should be combined with health services research methodology and the use of big data through linked national audit.
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Affiliation(s)
- Jugdeep Dhesi
- Perioperative medicine for Older People undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London
- Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London
| | - S Ramani Moonesinghe
- University College London Hospitals & National Institute of Health Biomedical Research Centre, London, UK
| | - Judith Partridge
- Perioperative medicine for Older People undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London
- Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London
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Regarding "Financial implications of coding inaccuracies in patients undergoing elective endovascular abdominal aortic aneurysm repair". J Vasc Surg 2019; 69:974-975. [PMID: 30798848 DOI: 10.1016/j.jvs.2018.10.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 10/29/2018] [Indexed: 11/22/2022]
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Nicol E. Sustainability in healthcare: efficiency, effectiveness, -economics and the environment. Future Healthc J 2018; 5:81. [PMID: 31098536 PMCID: PMC6502558 DOI: 10.7861/futurehosp.5-2-81] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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