New York City - 2014 Development of the Geriatric Collaborative
The Clinical Problem More than 50% persons age 65 years will have some surgical procedure in the remainder of his or her lifetime Outcome depends on physiologic state not just age Surgical morality is higher than in younger adults Death is often not the most important outcome* - Functional decline - Cognitive decline - Loss of independence * Fried T, et al. N Engl J Med 346(2), 2002
The Question How can we improve surgical decision making and the quality of surgical care for older patients in a way that: 1. Acknowledges physiologic differences 2. Respects the individual s goals and preferences
Quality Indicators for Surgery in Older Patients
Quality Indicators for Elderly Surgical Patients Modified Delphi Technique (RAND/UCLA) Identified candidate QIs From published reviews Semi-structured interviews of leaders across disciplines 96 candidate QI s (8 domains) Iterative panel ratings 13 member expert panel Rated validity twice (individually group) Valid if adequate scientific evidence or strong consensus and if higher adherence = higher quality 91 Valid Indicators 71 specific to the elderly McGory. Ann Surg 2009; 250:338
Quality Indicators for Elderly Surgical Patients McGory. Ann Surg 2009; 250:338
Institute of Medicine Report on Aging and Health Care April 2008 All licensure, certification, and maintenance of certification of healthcare professionals should include demonstration of competence in care of older adults as a criterion.
American Board of Surgery Sponsored Geriatric Competencies for Surgical Specialties ( J Amer Coll Surg 213:683-690, 2011) Sponsors: Participating Boards: Anesthesiology Colorectal Surgery General Surgery Urology ABS, AGS, Hartford Foundation, AMA Obstetrics and Gynecology Otolaryngology Thoracic Surgery Geriatricians & Competencies Experts
Competencies for Geriatric Surgical Care Reviewed existing materials Organized resulting competencies 3 phases of care (pre-, intra-, postop) Vetted Competencies by 149 geriatric surgeons Rated competencies Geriatric competencies (AAMC, ABIM/ABFM, Academy Emergency Medicine) Quality indicators (McGory/Ko) Essential, desirable, not desirable 38 First Level competencies Bell. JACS 2011; 213:683
Competencies for Geriatric Surgical Care Bell. JACS 2011; 213:683
JACS 202; 215:453, 2012
ACS NSQIP- AGS Best Practice Guideline: Optimal Preoperative Assessment of the Geriatric Surgical Patient Expert panel-rated best practices 21 content experts (surgeons/geriatricians) Concise, evidence-based Summary of the evidence Existing quality indicators & competencies Re-review of the literature/evidence Recommendations Assessments (screening tools, algorithms) Strategies / Suggested Interventions Draft of guidelines - refined by expert panel In four rounds of review
Preoperative Checklist ACS-NSQIP- AGS Best Practice Guidelines Cognitive assessment Screen for depression Risk for delirium Alcohol/ Substance use Cardiac Evaluation Pulmonary evaluation Functional status/ Falls Screen for Frailty Screen for Malnutrition Medication history Patient s goals Family support Order appropriate tests
ACS-NSQIP Elderly Measure Composite outcomes (SSI, VTE, cardiac, pulm, renal complications) Includes all cases in 65+ age group Patient/ procedure mix risk adjusted Gives odds ratio for each hospital Currently reported NQF endorsed
Subjective Adjustment of Risk
Chronologic Age and Comorbidity May Not be Enough
Measuring Frailty Multiple Domains Physical Phenotype Hct <35% Shrinking Albumin < 3.4mg/dl Weakness Charlson Comorbidity 3 Exhaustion ADL 5 Slowness MiniCog 3 Low Activity Falls 1 Pre-Frail 1-2 criteria Frail 3 criteria TUG 15 sec Pre-Frail 2-3 criteria Frail >3 criteria Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol: Med Sci 56A:M136, 2001 Robinson TN,, et al. Simple frailty score predicts postoperative Complications across specialties. Am J Surg 206:544-550,2013.
J am Coll Surg 210:901, 2010 N=594 (Elective) Not frail (58%) Pre-frail (1-2) (32%) Frail ( 3) (10%) Odds Ratio (95%C.I.) Odds Ratio (95% C.I.) Postoperative Complications Ref 2.06 (1.18-3.60) 2.54 (1.12-5.77) Prolonged Length of stay Ref 1.49 (1.24-1.80) 1.69 (1.28-2.23) Discharge to other than home Ref 3.16 (1.00-9.99) 20.48 (5.54-75.68)
Frailty Score Albumin < 3.4 ADL 5 Falls 1 MiniCog 3 (n=129) Complications Hct <35% (n=72) Charlson 3 TUG 15 sec 0-1 2-3 4+
Common Complications in Geriatric Patients Delirium Aspiration Polypharmacy Under/malnutrition (dehydration) Catheter related UTI Fall related injury Pressure ulcers Deconditioning Loss of functional independence
Adding Variables to NSQIP Why do we need more variables: We currently don t collect data on some of the risk factors for poor outcomes (frailty, cognitive status, falls) We currently don t collect data on many of the relevant geriatric outcomes (delirium, functional decline) What can we do with the data: Learn how we are doing with geriatric complications now Develop risk models that address relevant outcomes, to better inform patients & improve surgical decision making Implement and test strategies to mitigate the risks, to improve the outcomes
ACS-NSQIP Geriatric Collaborative Selecting the Variables Preop Variables Easy to collect Must capture frailty Cognition Function Mobility and falls Social vulnerability End of life issues Carefully defined
Dementia and Surgical Outcomes 30 day Morality Adjusted OR (95%CI) 1.56 (1.36-1.78) Retrospective cohort Any Complication 1.93 (1.86-2.00) Acute renal failure 1.55 (1.39-1.73) Pneumonia 2.44 (2.31-2.58) 18,923 with dementia Septicemia 2.02 (1.90-2.15) 75,962 controls Stroke 1.66 (1.57-1.75) UTI 1.62 (1.50-1.74) 207,693 pts > age 60 yrs Adjusted for sex, age, teaching hospital, income, urban, comorbidity, surgery type, anesthesia Hu CJ, et al. Postoperative adverse outcomes in surgical patients with dementia. World J Surg 36:205-58, 2012
Preoperative Cognitive Dysfunction and Long Term Postoperative Survival Robinson TN, et al. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. J Am Coll Surg 215:12-18, 2012
Preoperative Falls and Postoperative Outcomes Prospective Cohort 2005-2010 Age > 65 years Fallers Non-fallers p value One or more Complications 59% 25% 0.004 Institutional Discharge 52% 6% <0.001 Readmission (30 days) 19% 4% One or more complications 39% 15% 0.002 Institutional Discharge 62% 32% 0.001 Readmission (30 days) 23% 8% Colorectal (n=81) Cardiac (n=154) Jones TS, et al. Who would have thought? Asking an older adult if they have fallen predicts surgical outcome.(in press)
ACS-NSQIP Geriatric Collaborative Selecting the Variables Preop Variables Outcome variables Easy to collect Must capture frailty Easy to collect Geriatric complications Cognition Function Mobility and falls Social vulnerability End of life issues Carefully defined Delirium Functional Decline Falls Pressure ulcers Carefully defined
ACS-NSQIP Geriatric Collaborative Defining and Refining the Variables ACS Geriatric Surgery Task Force (Multiple iterations 2 years) ACS-NSQIP Clinical Support Group (Melissa Latus) Local SCR s (Marilyn Hirsch)
ACS-NSQIP Geriatric Collaborative Variables New Pre-op Risk Variables New Outcome Variables History of cognitive decline/dementia Post-operative delirium Competency status-patient consent Pressures Ulcers Use of mobility aid Functional health on discharge Previous fall within one year Fall risk on discharge Origin from home w or w/o support Postoperative use of mobility aid Palliative care upon admission New post- op DNR Palliative care consult Discharge with/without services
Identifying Collaborating Sites Home institutes of members of the ACSGeriatric Task Force Contacted AGS/ GSI graduates Solicited other hospitals in our states Announced at NSQIP annual meeting Advertised at the ACS Clinical Congress
ACS-NSQIP Geriatric Collaborative 19 (23) Community & University Hospitals Advocate Illinois Masonic Beaumont - Grosse Pointe Bridgeport Hospital Center Exempla Good Samaritan Exempla St. Joseph Hospital John Muir Medical -Concord John Muir Medical Walnut Creek Lawrence Memorial Hospital Mercy Hospital & Medical Center Munroe Regional Medical Center Penticton Regional Hospital Sentara RMH Medical Center Sinai Hospital of Baltimore William Beaumont- Royal Oak William Beaumont Troy Wyckoff Height Medical Center Winthrop Memorial Hospital Brigham and Women's Hospital Duke University Medical Center University of Connecticut University of North Carolina University of Virginia Health Yale School of Medicine
Working Together to Improve Care: The ACS-NSQIP Geriatric Collaborative better risk assessment for Improved surgical decision making Identify most important deficits to address Analyze the outcomes Analyze the outcomes Continue to improve models Implement evidence based models to address identified deficits Implement Guidelines Step 1. Adding geriatric variables January 2014 Time Quality Analyze the outcomes