Evaluations of postoperative transitions in care for older adults: a scoping review.

BACKGROUND: Most people having major surgery are over the age of 65. The transition out of hospital is a vulnerable time for older adults, particularly after major surgery. Research on postoperative transitions in care is growing, but it is not clear how postoperative transitions are being evaluated. The objective of this scoping review was to synthesize processes and outcomes used to evaluate postoperative transitions in care for older adults. METHODS: We conducted a scoping review that included articles evaluating a postoperative transition in care among adults aged > 65 having major elective surgery. We searched Medline (Ovid), EMBASE (Ovid), CINHAL, and Cochrane Central Register of Controlled Trials (CENTRAL) from their respective inception dates to April 6, 2021. We also searched The World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov from their respective inception dates to April 6, 2021. Screening and data extraction was completed by reviewers in duplicate. Data relevant to study design and objective, intervention description, and process or outcome evaluations were extracted. Process evaluations were categorized using the Ideal Transitions in Care Framework, and outcome evaluations were categorized using the Institute for Healthcare Improvement Triple Aim Framework. RESULTS: After screening titles and abstracts and full-text article review, we included 20 articles in our final synthesis. There was variability in the processes and outcomes used to evaluate postoperative transitions in care. The most common outcomes evaluated were health service utilization (n = 9), including readmission and Emergency Department visits, experiential outcomes (n = 9) and quality of life (n = 7). Process evaluations included evaluating the education provided to patients to promote self-management (n = 6), coordination of care among team members (n = 3) and outpatient follow-up (n = 3). Only two articles measured frailty, one article used theory to guide their evaluations and no articles engaged knowledge users. CONCLUSIONS: There is inconsistency in how postoperative transitions in care were evaluated. There is a need to use theories and to engage key stakeholders involved in postoperative transitions in care, including older adults and their caregivers, to identify the most appropriate approaches for developing and evaluating interventions to meaningfully improve care.

Association of frailty with outcomes in individuals with COVID-19: A living review and meta-analysis.

BACKGROUND AND OBJECTIVES: Frailty leaves older adults vulnerable to adverse health outcomes. Frailty assessment is recommended by multiple COVID-19 guidelines to inform care and resource allocation. We aimed to identify, describe, and synthesize studies reporting the association of frailty with outcomes (informed by the Institute for Healthcare Improvement's Triple Aim [health, resource use, and experience]) in individuals with COVID-19. DESIGN: Systematic review and meta-analysis. SETTING: Studies reporting associations between frailty and outcomes in the setting of COVID-19 diagnosis. PARTICIPANTS: Adults with COVID-19. MEASUREMENTS: Following review of titles, abstracts and full text, we included 52 studies that contained 118,373 participants with COVID-19. Risk of bias was assessed using the Quality in Prognostic studies tool. Our primary outcome was mortality, secondary outcomes included delirium, intensive care unit admission, need for ventilation and discharge location. Where appropriate, random-effects meta-analysis was used to pool adjusted and unadjusted effect measures by frailty instrument. RESULTS: The Clinical Frailty Scale (CFS) was the most used frailty instrument. Mortality was reported in 37 studies. After confounder adjustment, frailty identified using the CFS was significantly associated with mortality in COVID-19 positive patients (odds ratio 1.79, 95% confidence interval [CI] 1.49-2.14; hazard ratio 1.87, 95% CI 1.33-2.61). On an unadjusted basis, frailty identified using the CFS was significantly associated with increased odds of delirium and reduced odds of intensive care unit admission. Results were generally consistent using other frailty instruments. Patient-reported, cost and experience outcomes were rarely reported. CONCLUSION: Frailty is associated with a substantial increase in mortality risk in COVID-19 patients, even after adjustment. Delirium risk is also increased. Frailty assessment may help to guide prognosis and individualized care planning, but data relating frailty status to patient-reported outcomes are urgently needed to provide a more comprehensive overview of outcomes relevant to older adults.