Integrated care model tied to better postoperative outcomes for older adults


By Marilynn Larkin

NEW YORK (Reuters Health) – Among older adults, participation in an interdisciplinary perioperative care intervention is associated with fewer complications, shorter hospitalizations and more frequent discharges home compared to usual care, researchers say.

“The Perioperative Optimization of Senior Health (POSH) model involves close collaboration of geriatrics and surgery throughout the perioperative period,” said Dr. Shelley McDonald of Duke University Medical Center in Durham, North Carolina.

“The geriatric team provides expertise in specific interventions such as optimizing treatment for multiple chronic medical conditions, reduction of unnecessary medications, education on underutilized medications, enhancement of mobility and nutrition, and delirium risk mitigation,” she explained in an email to Reuters Health.

“Accounting for the broader context of aging and health in the perioperative period,” she said, “can improve identification of each patient’s personal goal for undergoing surgery, allows for better shared decision making prior to surgery and promotion of active involvement of the patient and engaging caregivers in the recovery process.”

Dr. McDonald and colleagues compared outcomes for 183 POSH patients with 143 controls who received usual care. On average, patients in the POSH group were older than those in the control group (75.6 vs. 71.9) and had more chronic conditions (10.6 vs. 8.5).

As reported in JAMA Surgery, online January 3, a greater proportion of POSH patients underwent laparoscopic procedures (50% vs. 38.5%), and the median length of stay was shorter for the POSH group (4 days vs. 6 days).

The POSH group also had lower post-surgery readmission rates at 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%) - and were more likely to be discharged home with self-care (62.3% vs. 51.1%).

POSH patients had a lower mean number of complications, despite a higher rate of documented delirium (28.4% vs. 5.6%).

No significant interactions were found between outcomes and either POSH participation or type of surgery.

Dr. McDonald said, “This model allows future research opportunities for determining the most efficacious perioperative interventions for patients based on each person’s unique vulnerabilities and surgical risk.”

“When geriatric syndromes are taken into consideration before surgery in a coordinated care model, it allows for previously unidentified issues, such as lack of access to food or cognitive impairment, to become prioritized,” she added.

“The patient and caregivers can then be connected to resources for support beyond the surgical encounter.”

Dr. Gerard Doherty of Brigham and Women’s Hospital in Boston, author of an accompanying editorial, told Reuters Health by email, “"This is excellent work by a group that is dedicated to optimizing the care for older or frail patients, and who have implemented a system to do this within their hospital.”

“Others have done similar work with similar results by involving pharmacists or hospitalists in perioperative care,” he noted.

“My reservations about this report are limited to the fact that medicine is a discipline dedicated to continuous improvement,” he said. “While the authors were implementing this system, other care processes in their hospital were also changing, such as more laparoscopic procedures and special care pathways for colon surgery preparation and recovery.”

“The important news is that patients did better as time went along, but it is likely that the improvement is at least in part due to factors other than POSH,” Dr. Doherty continued. “We must be careful not to ascribe too much credit (to the program).”

“For example, there is no reason why the POSH program would have led to less blood loss, as is reported to have occurred - but increased use of laparoscopic surgery would be expected to do so,” he observed.

“Finally,” he said, “to achieve the kind of results that we all ultimately aspire to will require involvement of the primary care physician or practice, in order to add the continuity and context of the patient's life and family.”

“Too often, when we set out to improve outcomes in hospital medicine, we take an insular approach focused on the hospital care,” he noted. “This approach leaves the primary care team out of the process.”


JAMA Surg 2018.

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