How hospitals are working to prepare at-risk older patients for surgery

Older patients undergo major surgery on a regular basis. However, a number of these patients are at risk for experiencing complications, functional decline and loss of independence after surgery.

With this in mind, Emily Finlayson, MD,  professor of surgery and health policy at University of California - San Francisco Medical Center, set out to determine how to improve outcomes for at-risk older patients.  

She began by looking at whether patients are undergoing interventions that will help them reach their overall health goals. In other words, should some patients receive other types of less invasive treatment besides surgery? Part of that decision involves assessing the patient's fitness for surgery, but another part involves understanding what the patient hopes to get out of the procedure, says Dr. Finlayson. Some patients may aim to live a longer life regardless the cost, while others may seek to maintain a high level of function and independence for as long as they can.

"So, sort of meeting patients where they are," she says. "I thought we needed to beef [that] up. I think surgeons currently aren't trained to have those granular conversations as well as some other specialists. Also, considering the time constraints and the clinic culture, the throughput doesn't really lend itself to that conversation."

Additionally, she says, hospitals are good at screening for major medical risk factors such as heart disease before surgery, but they don't routinely look for frailty components such as functional disability and poor social support.

Ultimately, after thinking about those issues, Dr. Finlayson helped start, and now directs, the UCSF Center for Surgery in Older Adults. The center includes UCSF's Surgery Wellness program, which is designed to help older patients get physically, mentally and logistically prepared for an operation.   

As part of the program, a geriatrician, occupational therapist, physical therapist and nutritionist provide consultations to the patient, who is accompanied by a student from the University of California Berkeley. The geriatrician ensures the patient is taking the appropriate medications and discusses care goals and advanced directives; the occupational therapist discusses the patient's home set up and ensures the patient's home is a safe place to recover after surgery; the physical therapist provides a safe exercise plan for the patient; and the nutritionist helps the patient choose healthy food prior to surgery, says Dr. Finlayson. The UC Berkeley student, known as a health coach, offers the patient individual support during surgery preparation. Following surgery, the health coach goes through the care plan with the patient.

Patient reaction to the program is mixed. "Some find this empowering, will take control. Others are so anxious about the operation they can't engage in any exercise or targeted optimization," she says. "So we have to make sure those are addressed as part of game plan. Some may need interventions to help with anxiety."

Other programs

UCSF Medical Center isn't the only organization with a program to help at-risk older patients prepare for surgery. Duke University Medical Center in Durham, N.C., and Ann Arbor-based Michigan Medicine implemented similar programs. And, Duke's Perioperative Optimization of Senior Health program has shown successful results. A study published last month in JAMA Surgery found older patients who participated in the program prior to elective abdominal surgery had shorter lengths of stay, lower readmissions, more frequent discharges home and fewer delirium and other major postoperative complications compared to nonparticipants.

Based on these and other successful program results, Dr. Finlayson is working on a website and digital app, Prehab Pal, to add to and disseminate UCSF Medical Center's program. Dr. Finlayson says such a solution is warranted, given that 90 percent of older patients at the Surgery Wellness program clinic have internet access, and 40 percent have tablets.

"If you design with the older user in mind, you can engage older patients. So we picked brains of providers, made algorithms, then set out to design it with our patients," she says. "We're trying to make it accessible and appealing to that population. It will do assessments, make recommendations and create daily plans to coach people through how to get ready for surgery."

Dr. Finlayson acknowledged the challenges with programs like the one at UCSF Medical Center is doing them in a sustainable way. After all, she says, clinics where such programs are provided are highly resource-intensive, and current reimbursement payment models don't necessarily support those types of clinics. That's why UCSF Medical Center started the program on a small scale — its program only accommodates about six older patients per week.

Her team is working on strategies to build on the existing program. Meanwhile, she believes healthcare organizations implementing programs like UCSF Medical Center's could bring more of a health and wellness approach to surgery, rather than a single approach to surgical conditions.

"Sometimes surgical pathways function as a kind of assembly line, one size fits all, and having the program inserts a pause to identify risks," she says. "We want to make sure patients know what they're signing up for. Also, [there are] potentially modifiable vulnerabilities they have that we can intervene on. For example, we can get social support in place, make that soft landing when they come home so it's not a rocky transition."

Improving the surgery quality for older adults nationwide is also the goal of the American College of Surgeons' Coalition for Quality in Geriatric Surgery Project, which is working to determine appropriate standards for hospitals that provide surgical care for older adults, according to Kaiser Health News. That effort to improve care before surgery will launch next year.  

 

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