The Coalition for Quality in Geriatric Surgery. Ronnie A. Rosenthal, MS, MD, FACS

Transcription

1 The Coalition for Quality in Geriatric Surgery Ronnie A. Rosenthal, MS, MD, FACS

2 Disclosures I receive an honorarium from the Coalition for Quality in Geriatric Surgery grant

3 The Aging U.S. Population Starting in 2012: 10,000 people will turn 65 each day By 2030: 20% of the population will be over age 65 years By 2050: Nearly 20 million will be over age 85 years More than 50% of persons> age 65 years will have some surgical procedure in the remainder of his or her lifetime

4 The Graying of America Percent of Total U.S. Population over Source of data: U.S. Census Bureau, State Interim Projections by Age and Sex: , Prepared by the UNC Institute on Aging

5 (Lancet 378:1408, October, 2011) Surgery in Medicare Recipients Deceased in 2008 Last year of Life 31.9% 34.4% month of life 18.3% week of life 8.0% 11.5%

6 He feared the operation that he had developed to treat this condition might, at his age (97), leave him mentally or physically crippled. I d rather die, he said. Michael Stravato for The New York Times The Patient Dr. Michael E. DeBakey, seated, became the oldest patient to benefit from heart surgery he devised By LAWRENCE K. ALTMAN Published: December 25, 2006

7 Treatment Preferences of Older Adults with a Likelihood of Adverse Outcome Treatment Intensity Low Burden High Burden Low Burden Health Outcome Return to Current Health Return to Current Health Functional Impairment Wants Treatment 98.7% 88.9% 25.6% Low Burden Cognitive Impairment 11.2% Fried TR, et al. N EnglJ Med 346(2), 2002 Rubin et al. JAMA IntMed, 176;1557-8, 2016

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9 Age and Traditional Surgical Outcomes y y 80+ y Bentremet al. Arch Surg. 2009; 144: Finlayson, Fan, Birkmeyer J Am Coll Surg 2007;205:

10 In 2015, at age 89, Angela Lansbury won an Olivier Award for best supporting Actress in Blithe Spirit playing on stage in London. She also toured with the show in US that year. At age 80, she had a total knee replacement and was thrilled with knee replacement surgery, saying it has allowed her to dance again.

11 Complexity of Frailty From: Fried LP a, Walston J. In Hazzard 4 th ed. 1998

12 The Metabolic and Inflammatory Consequences of Surgery Counterregulatory hormones Cortisol Catecholamines (Epi, NE) Glucagon Growth Hormone Cytokine Production IL6, IL1 TNFa Hepatic insulin resistance Peripheral insulin resistance IM Glucose Utilization Proteolysis Glucose and AA Lipolysis FFA Glucose Production Glycogenolysis Gluconeogenesis Glucose

13 When Frailty and Surgery Meet Counterregulatory hormones Cortisol Catecholamines (Epi, NE) Glucagon Growth Hormone Cytokine Production IL6, IL1 TNFa Peripheral insulin resistance Hepatic insulin resistance IM Glucose Utilization Proteolysis Lipolysis FFA Glucose Production Glycogenolysis Gluconeogenesis

14 Frailty and Surgical Outcomes Wahl TS, Graham L, Hawn MT et al. JAMA Surg. Published on line May 3, 2017

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17 ACS-NSQIP Geriatric Pilot- Measures that Matter (to Patients) Began in January Hospitals (U.S. and Canada) Patients 65 years and older 16 - variables covering in 4 domains Health Care Goals Function Mobility Cognition 3 variables for 30 day functional outcome ( 80 years)

18 ACS-NSQIP Geriatric Surgery Pilot Post-operative Delirium with Age 30 Percent (%) Delirium Y 70-74Y Y Y >85 Y Age Berian, J, et al.accepted for publication Annals of Surgery 2017

19 60% Postoperative Delirium and Other Surgical Outcomes 50% Total 40% cost estimates $16 to $64K per patient* % Patients 30% Potential $38 to $152 billion burden 20% ~ 30% of postop delirium is preventable 10% 0% Post-acute care discharge No Delirium (N=4,704) Serious morbidity* Delirium (N=614) 30-day mortality Berian J, et al.accepted for publication Annals of Surgery 2017, *Leslie DL, Inouye SK, J Am GeriatrSoc, 2011

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21 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

22 The Coalition for Quality in Geriatric Surgery (CQGS) Project Purpose: 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, teaching status or location.

23 The Coalition for Quality in Geriatric Surgery ( ) GOALS Engage Key Stakeholders Set the Standards Develop Measures that Matter to Patients Develop the Verification Process to Ensure Quality Educate Patients and Providers Pilot the Program Launch the Geriatric Surgery Quality Campaign

24 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 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

25 Stakeholder Input: Kickoff Meeting September, 2015 Get Perspective, Ideas and Buy-In Current State of Older Adult Surgical Care: Mapped Problems Future State of Older Adult Surgical Care: Top Priorities & How to Achieve

26 Literature Reviews Goals & Decision- Making Clinical Care 210 Pre-op Optimization Transitions of Care

27 Field Visits across the U.S.A. 11 Hospitals in 7 Cities 4 Community-based 3 Academic centers 1 ACO System 1 VA 1 Safety Net 1 Rural

28 Standards Development Process Stakeholder Input (58) Pre-and Peri-Op Guidelines & Literature Review (100s) Hospital Field Visits (11) Preliminary Standards (308) Targeted Stakeholder Calls (20)

29 Annals of Surgery: 2017 Section 1: Continuum of Care Goal Setting/ Decision Making (1-29) Preop Optimization (30-118) Transitions of Care ( ) Section 2: Clinical Care Immediate Preop( ) Intraop( ) Postop ( ) Section 3: Program Management ( ) Section 4: Outcomes and Follow Up ( )

30 Standards Development Process Preliminary Standards (308) Alpha Standards (92) Beta Standards (33) Focus on: Care concordant with goals Preservation of cognition Maintenance of function Internal team Consolidation Alpha Pilot -15 centers: Which are already in use? How hard would others be? Beta pilot 6 centers: Full implementation of 33 beta standards Fall 2017

31 CHAPTERS 1. Goals and Decision Making 2. Preoperative Optimization 3. Immediate Pre and Intraoperative Care 4. Postoperative Clinical Care 5. Transitions of Care 6. Program Management 7. Patient Outcomes and Follow-up November 2017

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33 CQGS Launch 2019 Geriatric Surgery Quality Summit