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Cited by 210Frailty in Older AdultsCardiac, Anesthesia and Surgical OutcomesEnhanced Recovery After Surgery

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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

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McDonald, Shelley R., Heflin, Mitchell T., Whitson, Heather E., Dalton, Thomas O., Lidsky, Michael E., Liu, Phillip, Poer, Cornelia M., Sloane, Richard, Thacker, Julie K., White, Heidi K., Yanamadala, Mamata, Lagoo-Deenadayalan, Sandhya A.·2018·JAMA Surgery
DOI 10.1001/jamasurg.2017.5513PMC PMC5875304
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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.

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Authors
McDonald, S. R., Heflin, M. T., Whitson, H. E., Dalton, T. O., Lidsky, M. E., Liu, P., Poer, C. M., Sloane, R., Thacker, J. K., White, H. K., Yanamadala, M., & Lagoo-Deenadayalan, S. A.
Affiliations
  • Memorial Sloan Kettering Cancer Center (US)
  • Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
Corresponding author
McDonald, Shelley R.
ORCID
Venue
JAMA Surgery
Publisher
American Medical Association (AMA)
Published
2018-05-01
Volume
153
Issue
5
Pages
454
ISSN
2168-6254 (ISSN-L)
DOI
10.1001/jamasurg.2017.5513
PMC
PMC5875304
OpenAlex
W2782332747
Cited by
210
References
39
Citations by year
2026: 26 · 2025: 18 · 2024: 36 · 2023: 27 · 2022: 28 · 2021: 33 · 2020: 22 · 2019: 13 · 2018: 7
FWCI
10.40
Type
journal article
Language
en
Open access
Locations
  • JAMA Surgery (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • John A. Hartford Foundation
  • Hartford Foundation for Public Giving
  • School of Medicine, Duke University
  • National Cancer Institute (P30CA008748)
Topics
  • Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
  • Health Sciences › Medicine › Surgery › Enhanced Recovery After Surgery
Keywords
integrated care coordination, older adults, elective abdominal surgery, perioperative optimization, geriatric surgery, postoperative complications, delirium, length of hospital stay, hospital readmission, discharge disposition, cognitive impairment, multimorbidity, polypharmacy, quality improvement
MeSH terms
Aged, Aged, 80 and over, Female, Follow-Up Studies, Humans, Length of Stay, Male, Morbidity, Patient Readmission, Postoperative Complications, Retrospective Studies, United States, Elective Surgical Procedures, Delivery of Health Care, Integrated, Perioperative Care

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