Building a Standards and Verification Program for Older Adults. Melissa Hornor, MD GSI/SEGUE Session: American Geriatric Society May 20, 2017

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1 Building a Standards and Verification Program for Older Adults Melissa Hornor, MD GSI/SEGUE Session: American Geriatric Society May 20, 2017

2 Disclosures ACS/JAHF James C. Thompson Geriatric Surgery Fellow, position supported by the John A. Hartford Foundation & American College of Surgeons

3 Primary Discussion Points Why improve quality in geriatric surgery? Coalition for Quality in Geriatric Surgery Standards Education Value

4 Primary Discussion Points Why improve quality in geriatric surgery? Coalition for Quality in Geriatric Surgery Standards Education Value

5 The Population is Aging Figure 1: Number of Persons 65+: (numbers in millions) Note: Increments in years are uneven. Source: U.S. Census Bureau, Population Estimates and Projections.

6 Geriatric Surgery is Common Disproportionate share of surgical procedures: 33% or 3.2 million OR procedures AHRQ HCUP 2014 Postop morbidity and mortality increases with age Finlayson et al J Am Coll Surg 2007 Functional outcomes are worse Loss of independence occurs in >50% of older adults after surgical procedures Berian et al 2016 JAMA Surg

7 Unique Healthcare Goals Older adults have different priorities: 75-89% would forgo lifesaving treatment if it meant severe functional or cognitive impairment May prioritize quality of life over quantity of life Fried et al NEJM 2002

8 Primary Discussion Points Why improve quality in geriatric surgery? Coalition for Quality in Geriatric Surgery Standards Education Value

9 The American College of Surgeons Quality Programs

10 Four Guiding Principles of Continuous Quality Improvement 1. Set the Standards - Highest clinical standards - Based on evidence - Individualize to the patient 3. Collect Robust Data - From medical charts - Post-discharge tracking - Continuously updated - Risk adjusted 2. Build the Right Infrastructure - Appropriate, adequate staffing levels, specialists, equipment and IT systems 4. Verify through a Third Party - External peer review - Establish public assurance

11 The Coalition for Quality in Geriatric Surgery (CQGS) Project Goal: To systematically improve the surgical care of older adults by establishing a verifiable quality improvement program with standards based on best evidence and focused on what matters most to the individual patient. Eligibility: All hospitals regardless of size, location or teaching status

12 Building CQGS 1. Engage Key Stakeholders 2. Set the Standards 3. Develop Measures that Matter 4. Develop the Verification Process 5. Pilot the Program 6. Educate Patients and Providers 7. Launch the Geriatric Surgery Quality Program

13 Primary Discussion Points Why improve quality in geriatric surgery? Coalition for Quality in Geriatric Surgery Standards Education Value

14 Standards Development Process 1 Preliminary Standards Alpha Standards Beta Standards Final Standards

15 Stakeholder Organizations AARP ACS Advisory Council for Rural Surgery ACS Committee on Surgical Palliative Care Aetna American Academy of Ophthalmology American Academy of Orthopaedic Surgeons/American Association of Orthopaedic Surgeons American Academy of Otolaryngology American Academy of Physical Medicine and Rehabilitation American College of Physicians American Geriatrics Society American Hospital Association, Health Research & Educational Trust American Society of Anesthesiologists American Society of Consultant Pharmacists American Society of PeriAnesthesia Nurses American Urological Association Association of perioperative Registered Nurses Association of VA Surgeons Carealign (Patient Priorities Care) Case Management Society of America Center to Advance Palliative Care Centers for Medicare and Medicaid Services Eastern Association for the Surgery of Trauma Family Caregiver Alliance Florida Hospital Association Geriatrics for Specialists Initiative Gerontological Advanced Practice Nurses Association Hartford Institute for Geriatric Nursing Hospital Elder Life Program Kaiser Permanente Memorial Sloan Kettering Cancer Center National Association of Social Workers National Committee for Quality Assurance National Gerontological Nursing Association Nurses Improving Care for Healthsystem Elders Patient and Family Centered Care Partners Penn Medicine Department of Anesthesiology & Critical Care Pharmacy Quality Alliance Society for Academic Emergency Medicine Society for Critical Care Medicine Society of General Internal Medicine Society for Hospital Medicine The American Association for the Surgery of Trauma The American Board of Surgery The American Congress of Obstetricians and Gynecologists The Beryl Institute The John A. Hartford Foundation The Society of Thoracic Surgeons University of Colorado/Care Transitions US Department of VA Geriatrics and Extended Care Yale New Haven Patient Experience Council UAB Division of Gerontology, Geriatrics and Palliative Care University of Chicago MacLean Center for Medical Ethics

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17 Preliminary Standards 308 standards 5 Chapters 1. Goals & Decision-Making 2. Preoperative Optimization 3. Transitions of Care 4. Clinical Care 5. Program Management

18 Standards Development Process 2 Preliminary Standards Alpha Standards Stakeholders rated validity and feasibility Beta Standards Final Standards

19 Stakeholder Ratings Using a modified RAND-UCLA Appropriateness Methodology, CQGS Stakeholders twice rated each standard on validity and feasibility 99% (306/308) rated as valid 94.2% (290/308) rated as feasible Ann Surg epub ahead of print

20 Alpha Standards 92 standards 7 Chapters 1. Goals & Decision-Making 2. Preoperative Optimization 3. Intraoperative Care 4. Postoperative Optimization 5. Transitions of Care 6. Program Management 7. Patient Outcomes & Follow-up

21 Standards Development Process Preliminary Standards 3 Alpha Standards Beta Standards 15 centers are they already implementing the standards, could they implement the standards? Final Standards

22 Alpha Pilot 15 participating hospitals, 20 invited = 75% response rate Goal = end user feedback on the alpha standards Ease of interpretation Baseline implementation Feasibility of implementation How well they unify with quality vision

23 Alpha Pilot 33% Academic 25 1,155 beds 73%

24 Alpha Pilot

25 Standards Chapter Alpha Pilot Findings Standards Already Implemented at Baseline 41/109 34/109 Standards Rated Difficult to Implement Chapter 1: Goals and Decision- 5/16 (31.0%) 2/16 (12.5%) Making 38% Widely Chapter 2: Preoperative 7/37 (18.9%) 31% Difficult 18/37 (48.6%) to Optimization Implemented Chapter 3: Immediate Implement at Baseline Preoperative and Intraoperative 5/7 (57.9%) 0/7 (0%) Clinical Care Chapter 4: Postoperative Clinical Care 11/19 (57.9%) 1/19 (5.3%) Chapter 5: Transitions of Care 1/6 (16.7%) 0/6 (0%) Chapter 6: Program Management Chapter 7: Patient Outcomes and Follow-Up 0/11 (0%) 6/11 (54.5%) 0/7 (0%) 7/7 (100%)

26 Alpha Pilot Conclusions We need to lower the burden Renewed focus on the standards that will profoundly impact the quality of surgical care for older adults Goals of Care and Decision-Making Cognitive and Function Preservation Optimize Nutrition and Hydration

27 Standards Development Process Preliminary Standards Alpha Standards Beta Standards Beta pilot 6 centers will actually implement the standards Final Standards

28 Primary Discussion Points Why improve quality in geriatric surgery? Coalition for Quality in Geriatric Surgery Standards Education Value

29 CQGS Education Patients Caregivers Providers Leverage Stakeholders

30 CQGS Education In-person course for geriatric surgery leaders Novel, interactive, and thought-provoking online modules with pre- and post-testing to measure comprehension Prototype course and modules will debut at American College of Surgeons Clinical Congress 2017 Module Topic How to preserve your function and mobility after surgery Caring for the older surgical patient after discharge Goals and decision-making in the older adult Audience Patients Caregivers Providers

31 Primary Discussion Points Why improve quality in geriatric surgery? Coalition for Quality in Geriatric Surgery Standards Education Value

32 Multicomponent Delirium Prevention Protocol # Standard The following standards apply to all inpatient surgical procedures, both elective and nonelective. 20 There must be pathways, bundles, or order sets in place for delirium: Prevent Sensory and mobility aids available Avoid restraints Avoid Beers criteria medications Control pain Recognize Daily screens Look for infection, metabolic derangement, dehydration, urinary retention/fecal impaction, occult alcohol or drug withdrawal, medication effect Treat Non-pharmacologic interventions first Pharmacologic interventions reserved only for patients who pose substantial harm to themselves or others 30% of delirium potentially preventable Siddiqi et al Cochrane Database Syst Rev

33 CQGS Value Calculator Leverage NSQIP Geriatric Pilot Data on postoperative delirium rates Procedure Delirium Rate Hip Fracture 38.01% Other Orthopedic 7.11% Peripheral Vascular 15.71% Esophagus 33.61% Colon 13.93%

34 % Patients CQGS Value Calculator Delirium Rate x Delirium Cost per episode = Hospital Cost 60% 40% 20% 0% Post-acute care discharge Serious morbidity* 30-day mortality No Delirium (N=4,704) Delirium (N=614) Procedure Type # of patients Baseline delirium rate Cost per episode Delirium Cost Hip Fracture % $8,373* $1,590,870 *Zywiel et al 2015 J Bone Joint Surg

35 Summary CQGS is a comprehensive, systematic program that will improve the quality of surgical care for older adults - Optimization of older surgical candidates - Alignment of patient goals and care provided - Improved collection of geriatric-centered outcomes - Integrated care across disciplines and phases Applicable to all hospitals regardless of size, location or teaching status

36 Acknowledgements Dr. Tim Pawlik Dr. Alan Harzman Dr. Susan Moffatt-Bruce Dr. David Hoyt Dr. Clifford Ko Dr. Ronnie Rosenthal Drs. Marcia Russell, Mark Katlic, Tom Robinson, Emily Finlayson, Sandhya Lagoo-Deenadalayan, JoAnn Coleman, Victoria Tang and Sanjay Mohanty Sameera Ali, Tracey Baker and Kitty Vineyard, Kataryna Christensen Marcus Escobedo

37 @hornormd #CQGS