Making a Financial Case for the Geriatric Surgery Verification Program.

Mini abstract The financial benefits of instituting the American College of Surgeons Geriatric Surgery Verification Program far exceed the costs, with the added benefits of enhanced patient satisfaction and improved staff morale.

Preoperative functional status is associated with discharge to nonhome in geriatric individuals.

INTRODUCTION: Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations. MATERIALS AND METHODS: A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression. RESULTS: The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01). CONCLUSION: Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes.

Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative.

BACKGROUND: The American College of Surgeons Coalition for Quality in Geriatric Surgery is a multidisciplinary stakeholder group that aims to systematically improve the surgical care of older adults by establishing a verifiable quality improvement program with standards based on best evidence. Prior work confirmed the validity of a preliminary set of 308 standards to improve the quality of geriatric surgery, but concerns exist as to whether the standards are feasible for hospitals to implement. OBJECTIVE: Our aim was to utilize data gained from a multi-institutional survey and interview to improve the scalability and generalizability of a geriatric quality improvement program. METHODS: Using a survey followed by a targeted debrief interview, 15 hospitals gathered an interdisciplinary panel to answer whether each standard was already in place at their institution, and if not, the perceived difficulty of implementation according to a five-point Likert scale (from 1 [very easy] to 5 [very difficult]). The standards were then placed into categories according to the hospital responses. Standards were designated "duplicative" if 11 or more hospitals reported baseline implementation, "prohibitively difficult" if 6 or more hospitals rated the standard as such, and "high potential" if they were neither duplicative nor difficult. A targeted debrief interview was then conducted with each participating hospital. RESULTS: Fifteen participating hospitals evaluated the feasibility of 108 standards and found 28 (26%) duplicative, 35 (32%) too difficult, and 45 (42%) high potential. Of the 108 standards, 49 (45%) were selected for the next iteration of standards, and 59 were removed. Among the standards that were removed, the majority (64%) were rated duplicative and/or difficult. CONCLUSION: A multi-institutional survey and interview successfully identified care standards that were redundant or too difficult to implement on the hospital level. These data will help improve the generalizability and scalability of the program while maintaining the overall goal of improving care. J Am Geriatr Soc 67:1074-1078, 2019.

Sinai Abbreviated Geriatric Evaluation: Development and Validation of a Practical Test.

OBJECTIVE: To develop and validate a simple geriatric screening tool that performs as well as more complex assessments BACKGROUND:: Many tools that predict treatment risk in older adults are impractical for routine clinical use. METHODS: We prospectively conducted comprehensive preoperative evaluations on 1025 patients age ≥75 years who presented to Sinai Hospital of Baltimore for major elective surgery, then retrospectively reviewed patients' medical records for occurrence of postoperative outcomes. Using logistic regression modeling and receiver operating characteristic curve analysis we selected the best combination of simple tests, labeling this the Sinai Abbreviated Geriatric Evaluation (SAGE). The performance of the SAGE was then compared with 3 standard tools in its power to predict postoperative outcomes. RESULTS: The SAGE is a statistically significant predictor of postoperative outcomes. Each unit decrease in SAGE score was significantly associated with a 51% (95% CI 1.30-1.77) increase in odds of a complication, a 2-fold increase in odds of postoperative delirium (95% CI 1.65-2.66), a 27% increase in odds of length of hospital stay >2 days (95% CI 1.10-1.47), a 54% increase in odds of a hospital readmission within 30 days (95% CI 1.25-2.88), and a 38% increase in odds of an unanticipated discharge to higher-level care (95% CI 1.18-1.61). We estimated the receiver operating characteristic curve area under the curve (AUC) for the SAGE of 0.69, 0.77, 0.73, 0.66, and 0.78 for the above outcomes, respectively. The SAGE performed as well in predicting postoperative outcomes as Fried's frailty phenotype, Charlson Comorbidity Index, and American Society of Anesthesiologists Physical Status Class (ASA). CONCLUSION: The SAGE performs as well as other geriatric evaluations that require equipment or memorization.

Application of the RAND-UCLA Appropriateness Methodology to a Large Multidisciplinary Stakeholder Group Evaluating the Validity and Feasibility of Patient-Centered Standards in Geriatric Surgery.

OBJECTIVES: To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions. DATA SOURCE/STUDY SETTING: Primary data (ratings) were reported from 58 stakeholder organizations. STUDY DESIGN: An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016. DATA COLLECTION/EXTRACTION METHODS: Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2). PRINCIPAL FINDINGS: In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3). CONCLUSIONS: There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group.

Five Hundred Seventy-Six Cases of Video-Assisted Thoracic Surgery Using Local Anesthesia and Sedation: Lessons Learned.

BACKGROUND: General anesthesia and endotracheal intubation are a luxury rather than a necessity for many video-assisted thoracic surgery (VATS) operations. Twenty-three years ago, I began using local anesthesia and sedation for pleural disease and subsequently, for pericardial and lung disease. STUDY DESIGN: The records of all patients undergoing VATS using local anesthesia and sedation at hospitals of the Geisinger Health System (Danville and Wilkes-Barre, PA), from June 1, 2002 to June 30, 2011, and the Lifebridge Health System (Baltimore, MD) from July 1, 2011 to March 1, 2017, were retrospectively reviewed. There was 1 unsuccessful attempt at this technique, and it was eligible for inclusion. No patient was excluded based on age, BMI, or comorbidities. No patient had endotracheal intubation, laryngeal mask airway, or epidural or nerve block analgesia; all patients breathed spontaneously. RESULTS: Five hundred twenty-nine patients ranging in age from 21 to 104 years (mean 67 years) underwent 576 procedures: pleural biopsy-drainage with or without talc (n = 368); drainage of empyema (n = 112); lung biopsy (n = 56); evacuation of chronic hemothorax (n = 23); pericardial window (n = 10); treatment of chylothorax (n = 2); lung abscess draining (n = 2); treatment of pneumothorax (n = 2); and mediastinal mass biopsy (n = 1). No patient required intubation or conversion to thoracotomy. There were 12 complications (2%). There were no deaths due to operation. CONCLUSIONS: Video-assisted thoracic surgery using local anesthesia and sedation is safe and effective for many indications. A review of the lessons learned caring for 529 patients will allow any thoracic surgeon and any anesthesiologist to practice this technique.

Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report From the Coalition for Quality in Geriatric Surgery.

OBJECTIVE: The aim of this study was to establish high-quality, valid standards to improve surgical care of the older adult. BACKGROUND: The aging population increases demand for high-quality surgical care. Building upon prior guidelines, quality indicators, and pilot projects, the Coalition for Quality in Geriatric Surgery (CQGS) includes 58 diverse stakeholder organizations committed to improving geriatric surgery. METHODS: Using a modified RAND-UCLA Appropriateness Methodology, 44 of 58 CQGS Stakeholders twice rated validity (primary outcome) and feasibility for 308 standards, ranging from goals and decision-making, pre-operative assessment and optimization, perioperative and postoperative care, to transitions of care beyond the acute care hospital. RESULTS: Three hundred six of 308 (99%) standards were rated as valid to improve quality of geriatric surgery. There were 4 sections. Section 1 included 157 (57%) standards and focused on goals and decision-making, preoperative optimization, and transitions into and out of the hospital. Section 2 included 84 (27.3%) standards focused on in-hospital care, across the immediate preoperative, intraoperative, and postoperative phases. Section 3 included 59 (19.1%) standards about program management, including personnel and committee structure, credentialing, and education. Section 4 included 8 (2.6%) standards establishing overarching concepts for data collection and patient follow-up. Two hundred ninety of 308 standards (94.2%) were rated as feasible; 18 (5.8%) were rated as uncertain in feasibility. CONCLUSIONS: CQGS Stakeholders rated the vast majority of standards of care as highly valid (99%) and feasible (94%) for improving the quality of surgical care provided to older adults. Future work will focus on a pilot phase to better understand and address challenges to implementation of the standards.

Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective.

The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.

Non-intubated video-assisted thoracic surgery in patients aged 80 years and older.

BACKGROUND: Video-assisted thoracic surgery (VATS) is routinely performed with general anesthesia and double-lumen endotracheal intubation, but this technique may stress an elderly patient's functional reserve. We chose to study the safety and efficacy of non-intubated VATS, utilizing local anesthesia, sedation, and spontaneous ventilation in the elderly. METHODS: The medical records of all patients aged 80 years and older who underwent VATS under local anesthesia and sedation during the time period 6/1/2002 to 6/1/2010 at Geisinger Health System (Pennsylvania, USA) and 10/1/2011 to 12/31/2014 at Sinai Hospital (Maryland, USA) were retrospectively reviewed. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on comorbidity. RESULTS: A total of 96 patients ranging in age from 80 to 104 years underwent 102 non-intubated VATS procedures: pleural biopsy/effusion drainage with or without talc 73, drainage of empyema 17, evacuate hemothorax 4, pericardial window 3, lung biopsy 2, treat chylothorax 2, treat pneumothorax 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent procedure or biopsy. Complications occurred in three patients (3.1% morbidity): cerebrovascular accident, pulmonary embolism, prolonged air leak. One 94-year-old patient died from overanticoagulation and two 84-year-old patients died of their advanced lung cancers (3.1% morbidity). CONCLUSIONS: Non-intubated VATS utilizing local anesthesia and sedation in the elderly is well tolerated and safe for a number of indications.

Non-intubated video-assisted thoracic surgery as the modality of choice for treatment of recurrent pleural effusions.

This review will establish that the best mode of treatment for recurrent pleural effusions is non-intubated video-assisted thoracic surgery (VATS) with chemical talc pleurodesis. The nature of recurrent pleural effusions mandates that any definitive and effective treatment of this condition should ideally provide direct visualization of the effusion, complete initial drainage, a low risk outpatient procedure, a high patient satisfaction rate, a high rate of pleurodesis and a high diagnostic yield for tissue diagnosis. There are various methods available for treatment of this condition including thoracostomy tube placement with bedside chemical pleurodesis, thoracentesis, placement of an indwelling pleural catheter, pleurectomy and VATS drainage with talc pleurodesis. Of these treatment options VATS drainage with the use of local anesthetic and intravenous sedation is the method that offers most of the desired outcomes, thus making it the best treatment modality.

Geriatric surgery--evolution of a clinical community.

BACKGROUND: We reviewed the current scientific data and opinions from thought leaders in the field of surgery in the elderly population and queried whether a new society should be formed. METHODS: The science of geriatric surgery (GS) was reviewed, including topics scientific sessions focused on GS. A town hall meeting was held, which included geriatric surgical scholars. A survey was created to define the interest in GS as a specialty society was sent to surgical scholars. RESULTS: As the volume of GS scholarly work has increased, the focus of geriatric science has migrated toward clinical studies on frailty and geriatric syndromes. Our town hall meeting outlined the need for a multidisciplinary GS team. Our survey documented more interest in multidisciplinary sessions at national meetings rather than a new, unique society. CONCLUSIONS: GS as a discipline is a multidisciplinary practice. Our data suggest that this unique characteristic speaks to the development of a clinical community rather than an independent society.