New program improves outcomes for older people undergoing elective surgery

Jan 5 2018

Compared to younger adults, older people have higher rates of complications from surgery. But many problems can be avoided by intervening with assessments and risk-reduction strategies before, during and after procedures.

The effort -- a program developed at Duke Health called Perioperative Optimization of Senior Health, or POSH – was established in June 2011 by co-directors Sandhya Lagoo-Deenadayalan, M.D., Ph.D., a general surgeon, and Mitchell Heflin, M.D., a geriatrician, with support from the Departments of Surgery and Medicine.

It includes a coordinated approach by surgery, geriatrics and anesthesiology to help older patients make an informed decision about proceeding with and preparing for elective surgeries in order to have the best possible outcomes.

Published Jan. 3 in JAMA Surgery, the researchers report that redesigning care resulted in shorter hospitals stays, lower readmission rates and a greater likelihood that patients would be discharged directly home without a nursing home stay or need for home health care. Patients in the POSH program also had overall fewer complications during their hospitalization.

"Our study shows that older adults do better when we proactively identify individual risks -- particularly those associated with aging -- and implement optimization strategies across a longer preoperative and postoperative timeframe," said lead author and geriatrics specialist Shelley McDonald, D.O., Ph.D., assistant professor of medicine at Duke. "This is a growing need as the population ages, and these results demonstrate that by preparing patients and their caregivers for surgery we can improve outcomes for older people undergoing elective surgery."

The Duke team focused on older patients planning to undergo elective abdominal surgeries. The patients were at least 65 years old, with one or more health factors that put them at higher risk of complications from surgery, including cognitive impairment, recent weight loss, chronic diseases, multiple medication needs, mobility difficulties and frailty.

From 2011-2015, the researchers evaluated a subset of patients enrolled in the POSH program, and compared their outcomes to those who underwent similar surgeries but did not have the intervention. The POSH patients tended to be older and had a higher number of chronic health conditions.

Following evaluation by surgeons, patients were referred to the POSH clinic where they were seen jointly by a multidisciplinary team, including geriatricians and anesthesia nurse practitioners. The team conducted a comprehensive risk assessment, then developed risk-mitigation strategies for patients and families to work on ahead of the surgery. Following surgery, the geriatrics team assisted the surgeons with post-operative management, focusing particularly on preventing complications and preparing for the transition from hospital to home.

Patients enrolled in the POSH program had shorter hospital stays by an average of two days. They also had lower readmission rates, with 2.8 percent of POSH patients readmitted within seven days of discharges, and 7.8 percent within 30 days of discharge. This compared to 9.9 percent of standard-care patients being readmitted at seven days, and 18.3 percent at 30 days.

Despite a having a lower overall complication rate, POSH patients were diagnosed more often with delirium. This might have been related to more rigorous surveillance for this condition by the geriatrics team. Regardless, a higher percentage of POSH surgery patients with delirium returned home upon discharge after surgery (62 percent) when compared to standard care patients (51 percent).

"Developing an interdisciplinary approach to treating older people undergoing surgery is an important step toward improving surgical outcomes, and what we learn from our collaboration will inform which elements of team-based care have the greatest impact so this can be more widely scaled to all health care settings," McDonald said.