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Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative.
JAMA Surg 2018; 153(5):454-462JS

Abstract

Importance

Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients.

Objective

To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization.

Design, Setting, and Participants

Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH.

Main Outcomes and Measures

Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets.

Results

One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes.

Conclusions and Relevance

Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Authors+Show Affiliations

Department of Medicine, Duke University Medical Center, Durham, North Carolina. Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina. Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Department of Medicine, Duke University Medical Center, Durham, North Carolina. Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina. Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Department of Medicine, Duke University Medical Center, Durham, North Carolina. Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina. Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Department of Medicine, University of Texas Southwestern Medical Center, Dallas.Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.Department of Medicine, Duke University Medical Center, Durham, North Carolina.Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Department of Surgery, Duke University Medical Center, Durham, North Carolina.Department of Medicine, Duke University Medical Center, Durham, North Carolina. Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Department of Medicine, Duke University Medical Center, Durham, North Carolina. Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina. Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina. Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina. Department of Surgery, Duke University Medical Center, Durham, North Carolina.

Pub Type(s)

Comparative Study
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

29299599

Citation

McDonald, Shelley R., et al. "Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: the Perioperative Optimization of Senior Health (POSH) Initiative." JAMA Surgery, vol. 153, no. 5, 2018, pp. 454-462.
McDonald SR, Heflin MT, Whitson HE, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg. 2018;153(5):454-462.
McDonald, S. R., Heflin, M. T., Whitson, H. E., Dalton, T. O., Lidsky, M. E., Liu, P., ... Lagoo-Deenadayalan, S. A. (2018). Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surgery, 153(5), pp. 454-462. doi:10.1001/jamasurg.2017.5513.
McDonald SR, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: the Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg. 2018 05 1;153(5):454-462. PubMed PMID: 29299599.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. AU - McDonald,Shelley R, AU - Heflin,Mitchell T, AU - Whitson,Heather E, AU - Dalton,Thomas O, AU - Lidsky,Michael E, AU - Liu,Phillip, AU - Poer,Cornelia M, AU - Sloane,Richard, AU - Thacker,Julie K, AU - White,Heidi K, AU - Yanamadala,Mamata, AU - Lagoo-Deenadayalan,Sandhya A, PY - 2018/1/5/pubmed PY - 2019/10/1/medline PY - 2018/1/5/entrez SP - 454 EP - 462 JF - JAMA surgery JO - JAMA Surg VL - 153 IS - 5 N2 - Importance: Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. Objective: To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Design, Setting, and Participants: Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Main Outcomes and Measures: Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. Results: One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. Conclusions and Relevance: Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group. SN - 2168-6262 UR - https://www.unboundmedicine.com/medline/citation/29299599/Association_of_Integrated_Care_Coordination_With_Postsurgical_Outcomes_in_High_Risk_Older_Adults:_The_Perioperative_Optimization_of_Senior_Health__POSH__Initiative_ L2 - https://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2017.5513 DB - PRIME DP - Unbound Medicine ER -