January 05, 2018
A recent study in JAMA Surgery found that a perioperative optimization initiative among high-risk older adults who recently underwent surgery decreased complications, hospitalizations, and readmissions.
“The growing number of older adults in the United States presents a specific set of challenges and opportunities for surgeons,” Shelley R McDonald, DO, PhD, of the department of medicine at the Duke University Medical Center, and colleagues wrote. “Postoperative complications likely result in slower recovery, longer postoperative hospital stays, more complex care needs at discharge, loss of independence, and higher readmission rates in the acute postoperative period.”
In order to mitigate these issues, the researchers developed the Perioperative Optimization of Senior Health (POSH) program—an integrated care coordination program for older adults undergoing elective surgeries.
“The main objective of the POSH program is to improve postoperative outcomes for this high-risk population,” the researchers wrote. “The model involves geriatrics experts throughout the perioperative period with specific targeted interventions such as management of comorbidities, reduction of polypharmacy, enhancement of mobility and nutrition, and delirium risk mitigation.”
The researchers compared 183 high-risk patients from the POSH program to 143 who received standard care.
Study results showed that while the intervention group patients were older, had a higher morbidity, and had more chronic conditions—the POSH program resulted in fewer complications despite higher rates of documented delirium. Furthermore, the POSH program group experienced shorter hospitalizations, were more frequently discharged to home, and had fewer readmissions—compared to the control group.
“Development of an interdisciplinary perioperative program featuring collaboration between health care professionals in surgery, geriatrics, and anesthesiology and focused on surgical risk mitigation, health optimization, and patient and family caregiver engagement was associated with improved postoperative outcomes for high-risk older adults undergoing elective abdominal surgery,” Dr McDonald and colleagues concluded. “To move this model forward, capturing high-quality data in clinical settings and refining the analyses will be crucial for identifying which elements of team-based care have the greatest impact for complex high-risk populations, thus enabling us to make better decisions about delivery of interventions at appropriate time intervals with respect to elective surgeries and directed toward those with the greatest opportunity for benefit.”
Gerard M Doherty, MD, of the department of surgery at the Harvard Medical School and Brigham and Women’s Hospital, wrote in an editorial that the findings presented by Dr McDonald and colleagues are marred by a lack of parity between the control group and the intervention groups. However, Dr Doherty also noted that the study highlights the usefulness of integrated care programs in older adults.
“Surgeons should remember that an important and often overlooked participant in the surgical care of patients is the primary care clinician, who might also be a geriatrician,” Dr Doherty wrote. “Consider not only bringing them into the preoperative discussion and postoperative planning, but also ensure that they know of the discretionary availability of programs like POSH so that they might help to initiate their appropriate use.”
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