CHICAGO: Proposed quality standards for improving the surgical care of older adults received feedback from a sample of North American hospitals, and those deemed most feasible to implement are undergoing pilot testing before a national rollout, the American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (the Coalition) reports. Results of this feasibility process have been published in the May issue of the Journal of the American Geriatrics Society. These standards define the resources the nation’s surgical facilities need to have in place to perform operations effectively, efficiently, and safely in older adults.
Surgical care for older adults is often fragmented, with great variation, said study coauthor and Coalition coprincipal investigator Clifford Y. Ko, MD, MS, MSHS, FACS, who also directs the ACS Division of Research and Optimal Patient Care. With the goal of improving care in the large U.S. population ages 65 and older—projected to exceed 56 million by next year1—the ACS and 58 other stakeholder organizations formed the multidisciplinary Coalition in 2015 with support from The John A. Hartford Foundation.
“The aim of the Coalition is to ensure as much as possible that surgical care for older adults is evidence-based and standardized, has optimal outcomes with low complication rates, and that the outcomes are those that are important to patients,” said Dr. Ko, a colorectal surgeon, who also is a professor of surgery at the University of California-Los Angeles David Geffen School of Medicine. “The Coalition helped to identify topic areas for hospital-level standards, including the resources, infrastructure, and clinical processes that must be put in place in order to obtain optimal outcomes for geriatric surgical patients.”
The standards reflect scientific evidence and expert opinion of what improves care and surgical patient outcomes in older adults. These factors include team-based care between geriatricians, surgeons, and other specialists; evaluating a patient’s risks of undergoing an operation, including screening for and reducing frailty, an age-related decline in function2; and using enhanced postoperative recovery protocols to reduce complications that occur more often in elderly patients.
For this initiative, 15 hospitals—one in Canada and 14 in the U.S.—participated in a study designed to prioritize a list of over 100 preliminary standards based on existing quality measures and previous work by the ACS, American Geriatrics Society, and The John A. Hartford Foundation.
To complete the survey, the hospitals, which the investigators considered diverse in size, type, location, and resources, each gathered an interdisciplinary group involved in the care of older adults undergoing operations. Participants answered whether each standard already was in place at their hospital and, if not, the perceived difficulty of implementing the standards given the hospital’s current resources. The Coalition core development team designated standards as duplicative if 11 or more hospitals had implemented it, prohibitively difficult if six or more hospitals rated it difficult, or high potential if it was neither duplicative nor difficult.
The development team later held conference calls with each hospital to ask about barriers to implementation and to gather more information.
The researchers found that 28 of 108 standards were duplicative, 35 were too difficult to implement, and 45 were of high potential. The researchers removed most of the duplicative and difficult standards and selected 49 standards for consideration. Since then, they refined the number of standards to approximately 30, which are currently undergoing pilot testing at eight hospitals, Dr. Ko stated.
“We now have an actionable number of metrics that we hope all hospitals caring for geriatric patients can adhere to,” Dr. Ko said.
The finalized standards will be made public in July at the ACS Quality and Safety Conference in Washington, D.C. The work of the Coalition will lead to a voluntary quality and resource verification program for participating hospitals called the ACS Geriatric Surgery Verification Program, he noted.
Dr. Ko emphasized two geriatric surgery standards in particular that he said “would make care phenomenally better for older adults if used by every hospital”: align patient goals with treatment and optimizing the patient for an operation before the procedure.
Older adults, typically defined as age 65 or older, often have unique physiological and social needs, and unique goals of care. For instance, Dr. Ko said a 99-year-old patient with a slow-growing non-symptomatic cancer, after being fully informed of the risks of surgically removing the cancer versus monitoring it, may choose to not have the operation.
“We should consistently individualize surgical care to the patient’s preferences and goals of care, but right now this process is too variable,” he said.
Feedback obtained from interviews with hospital staff, according to the article, included comments that use of the Coalition standards would better standardize geriatric care among hospital departments and that a verification program would show impact in all surgical subspecialties.
Another study author, Ronnie A. Rosenthal, MD, MS, FACS, Coalition coprincipal investigator, and professor of surgery and geriatrics at Yale University School of Medicine, said, “This feasibility analysis is an important step in our journey to provide safe, high-quality surgical care for older patients nationwide. We strived to make the standards meaningful without being so burdensome that hospitals would find it difficult to implement them.”
“We have a rapidly growing number of older adults with complex conditions who are undergoing surgery at increasingly advanced age,” said Terry Fulmer, PhD, RN, FAAN, President of The John A. Hartford Foundation. “The careful development and piloting of these new standards to ensure they are both feasible and significant in reducing harm and improving outcomes means that hospitals across the country will soon have a way of assuring the public that they are reliably delivering age-friendly surgical care that meets the needs of older adults.”
A grant from The John A. Hartford Foundation funded this work. Lead author, Melissa Hornor, MD, was the ACS John A. Hartford Foundation James C. Thompson Clinical Scholar-in-Residence at the ACS from 2016 to 2018 when this research was conducted. In addition to Drs. Ko, Rosenthal, and Hornor, other coauthors are Victoria L. Tang, MD, MAS; Julia Berian, MD, MS; Thomas N. Robinson, MD; JoAnn Coleman, DNP; Mark R. Katlic, MD, MMM; Kataryna Christensen; Tracey Baker; Emily Finlayson, MD, MS; Sandhya A. Lagoo-Deenadaayalan, MD, PhD; and Marcia M. Russell, MD.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
Citation: Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative, Journal of the American Geriatrics Society. Available at: https://doi.org/10.1111/jgs.15815.
- US Census Bureau. Older Americans Month: 2018. Table 2. https://www.census.gov/newsroom/stories/2018/older-americans.html.
- Mrdutt MM, Papaconstantinou HT, Robinson BD, Bird ET, Isbell CL. Preoperative frailty correlates with surgical outcomes across diverse surgical subspecialties in a large healthcare system. J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2018.12.036.
