Advertisement

Geriatric Comanagement of Older Vascular Surgery Inpatients Reduces Hospital-Acquired Geriatric Syndromes

  • Janani Thillainadesan
    Correspondence
    Address correspondence to Janani Thillainadesan, MD, PhD, Department of Geriatric Medicine, Concord Hospital, Building 12, Hospital Rd, Concord, NSW 2139, Australia.
    Affiliations
    Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia

    Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia

    Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
    Search for articles by this author
  • Sarah J. Aitken
    Affiliations
    Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia

    Concord Institute of Academic Surgery, Vascular Surgery Department, Concord Hospital, Concord, Sydney, Australia

    Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
    Search for articles by this author
  • Sue R. Monaro
    Affiliations
    Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia

    Susan Wakil School of Nursing, The University of Sydney, Sydney, Australia
    Search for articles by this author
  • John S. Cullen
    Affiliations
    Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia

    Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia

    Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
    Search for articles by this author
  • Richard Kerdic
    Affiliations
    Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
    Search for articles by this author
  • Sarah N. Hilmer
    Affiliations
    Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, St Leonards, Sydney, Australia
    Search for articles by this author
  • Vasi Naganathan
    Affiliations
    Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia

    Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia

    Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
    Search for articles by this author
Published:October 28, 2021DOI:https://doi.org/10.1016/j.jamda.2021.09.037

      Abstract

      Objective

      This study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes.

      Design, Setting, and Participants

      A pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February–October 2019) and prospectively recruited postintervention (January–December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65 years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2 days were recruited.

      Intervention

      A comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions.

      Methods

      Primary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status.

      Results

      There were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P = .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P = .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P = .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium.

      Conclusions and Implications

      This is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Fowler A.J.
        • Abbott T.E.F.
        • Prowle J.
        • Pearse R.M.
        Age of patients undergoing surgery.
        Br J Surg. 2019; 106: 1012-1018
        • Jim J.
        • Owens P.L.
        • Sanchez L.A.
        • Rubin B.G.
        Population-based analysis of inpatient vascular procedures and predicting future workload and implications for training.
        J Vasc Surg. 2012; 55: 1394-1399
        • Ness J.
        • Aronow W.S.
        Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice.
        J Am Geriatr Soc. 1999; 47: 1255-1256
        • Partridge J.S.
        • Harari D.
        • Martin F.C.
        • et al.
        Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery.
        Br J Surg. 2017; 104: 679-687
        • Houghton J.S.M.
        • Nickinson A.T.O.
        • Bridgwood B.
        • et al.
        Prevalence of cognitive impairment in individuals with vascular surgical pathology: A systematic review and meta-analysis.
        Eur J Vasc Endovasc Surg. 2021; 61: 664-674
        • Houghton J.S.M.
        • Nickinson A.T.O.
        • Morton A.J.
        • et al.
        Frailty factors and outcomes in vascular surgery patients: A systematic review and meta-analysis.
        Ann Surg. 2020; 272: 266-276
        • Aitken S.J.
        • Blyth F.M.
        • Naganathan V.
        Incidence, prognostic factors and impact of postoperative delirium after major vascular surgery: A meta-analysis and systematic review.
        Vasc Med. 2017; 22: 387-397
        • Goldberg T.E.
        • Chen C.
        • Wang Y.
        • et al.
        Association of delirium with long-term cognitive decline: A meta-analysis.
        JAMA Neurol. 2020; 77: 1-9
        • Zhang L.M.
        • Hornor M.A.
        • Robinson T.
        • et al.
        Evaluation of postoperative functional health status decline among older adults.
        JAMA Surg. 2020; 155: 950-958
        • Aitken S.J.
        • Thillainadesan J.
        • Monaro S.
        • Naganathan V.
        Collaborative models of care for older vascular surgery patients admitted to hospital.
        ANZ J Surg. 2020; 90: 1232-1233
        • American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)/American Geriatrics Society (AGS)
        ACS NSQIP/AGS best practice guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient. [Internet].
        (Available at:)
        • American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)/American Geriatrics Society (AGS)
        Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the ACS NSQIP/American Geriatrics Society. [Internet].
        (Available at:)
        • Eamer G.
        • Taheri A.
        • Chen S.S.
        • et al.
        Comprehensive geriatric assessment for older people admitted to a surgical service.
        Cochrane Database Syst Rev. 2018; 1: Cd012485
        • Khadaroo R.G.
        • Warkentin L.M.
        • Wagg A.S.
        • et al.
        Clinical effectiveness of the elder-friendly approaches to the surgical environment initiative in emergency general surgery.
        JAMA Surg. 2020; 155: e196021
        • Shahrokni A.
        • Tin A.L.
        • Sarraf S.
        • et al.
        Association of geriatric comanagement and 90-day postoperative mortality among patients aged 75 years and older with Cancer.
        JAMA Netw Open. 2020; 3: e209265
        • Braude P.
        • Goodman A.
        • Elias T.
        • et al.
        Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of Older People undergoing Surgery (POPS)-Urology.
        BJU Int. 2017; 120: 123-129
        • Mitchell E.
        • Coary R.
        • White P.
        • et al.
        Daily Medical liaison is associated with reduced length of stay and complications in selected patients admitted to a regional vascular surgery service.
        Geriatrics (Basel). 2020; 5
        • Ritter J.C.
        • Maher S.
        • Bharat C.
        • et al.
        As the population is aging the surgical care model needs refreshment: Implementation of a vasculogeriatric service for vascular surgical patients in Australia.
        Clin Surg. 2016; 1
        • Ogrinc G.
        • Davies L.
        • Goodman D.
        • et al.
        SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process.
        J Contin Educ Nurs. 2015; 46: 501-507
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • et al.
        Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 348: g1687
        • Bellelli G.
        • Morandi A.
        • Davis D.H.
        • et al.
        Validation of the 4AT, a new instrument for rapid delirium screening: A study in 234 hospitalised older people.
        Age Ageing. 2014; 43: 496-502
        • Rockwood K.
        • Song X.
        • MacKnight C.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Thillainadesan J.
        • Jansen J.
        • Close J.
        • et al.
        Geriatrician perspectives on perioperative care: A qualitative study.
        BMC Geriatr. 2021; 21: 68
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • et al.
        Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Harris P.A.
        • Taylor R.
        • Minor B.L.
        • et al.
        The REDCap consortium: Building an international community of software platform partners.
        J Biomed Inform. 2019; 95: 103208
        • Hodkinson H.M.
        Evaluation of a mental test score for assessment of mental impairment in the elderly.
        Age Ageing. 1972; 1: 233-238
        • Inouye S.K.
        • van Dyck C.H.
        • Alessi C.A.
        • et al.
        Clarifying confusion: The confusion assessment method. A new method for detection of delirium.
        Ann Intern Med. 1990; 113: 941-948
        • Thillainadesan J.
        • Mudge A.M.
        • Aitken S.J.
        • et al.
        The prognostic performance of frailty for delirium and functional decline in vascular surgery patients.
        J Am Geriatr Soc. 2021; 69: 688-695
        • Heinze G.
        • Dunkler D.
        Five myths about variable selection.
        Transpl Int. 2017; 30: 6-10
        • Sutherland K.
        • Chessman J.
        • Zhao J.
        • et al.
        Impact of COVID-19 on healthcare activity in NSW, Australia.
        Public Health Res Pract. 2020; 30
        • Leung S.
        • Al-Omran M.
        • Greco E.
        • et al.
        Monitoring the evolving impact of COVID-19 on institutional surgical services: Imperative for quality improvement platforms.
        Br J Surg. 2021; 108: e7-e8
        • Sena G.
        • Gallelli G.
        An increased severity of peripheral arterial disease in the COVID-19 era.
        J Vasc Surg. 2020; 72: 758
        • Fried T.R.
        • Bradley E.H.
        • Towle V.R.
        • Allore H.
        Understanding the treatment preferences of seriously ill patients.
        N Engl J Med. 2002; 346: 1061-1066
        • Cheung C.
        • Meissner M.A.
        • Garg T.
        Incorporating outcomes that matter to older adults into surgical research.
        J Am Geriatr Soc. 2021; 69: 618-620
        • Silva A.R.
        • Regueira P.
        • Albuquerque E.
        • et al.
        Estimates of geriatric delirium frequency in noncardiac surgeries and its evaluation across the years: A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2020; 22: 613-620
        • Gleason L.J.
        • Schmitt E.M.
        • Kosar C.M.
        • et al.
        Effect of delirium and other major complications on outcomes after elective surgery in older adults.
        JAMA Surg. 2015; 150: 1134-1140
        • Taylor D.
        • Lewis Sn
        Delirium.
        J Neurol Neurosurg Psychiatry. 1993; 56: 742
        • American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults
        American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults.
        J Am Geriatr Soc. 2015; 63: 142-150
        • Morrison R.S.
        • Magaziner J.
        • Gilbert M.
        • et al.
        Relationship between pain and opioid analgesics on the development of delirium following hip fracture.
        J Gerontol A Biol Sci Med Sci. 2003; 58: 76-81
        • Thillainadesan J.
        • Yumol M.F.
        • Hilmer S.
        • et al.
        Interventions to improve clinical outcomes in older adults admitted to a surgical service: A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2020; 21: 1833-1843
        • Marcantonio E.R.
        • Flacker J.M.
        • Wright R.J.
        • Resnick N.M.
        Reducing delirium after hip fracture: A randomized trial.
        J Am Geriatr Soc. 2001; 49: 516-522
        • Thillainadesan J.
        • Hilmer S.
        • Close J.
        • et al.
        Geriatric medicine services for older surgical patients in acute hospitals: Results from a binational survey.
        Australas J Ageing. 2019; 38: 278-283
        • Joughin A.L.
        • Partridge J.S.L.
        • O'Halloran T.
        • Dhesi J.K.
        Where are we now in perioperative medicine? Results from a repeated UK survey of geriatric medicine delivered services for older people.
        Age Ageing. 2019; 48: 458-462
        • McDonald S.R.
        • Heflin M.T.
        • Whitson H.E.
        • 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: 454-462
        • Engelhardt K.E.
        • Reuter Q.
        • Liu J.
        • et al.
        Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients.
        J Trauma Acute Care Surg. 2018; 85: 167-173
        • Shaw M.
        • Pelecanos A.M.
        • Mudge A.M.
        Evaluation of internal medicine physician or multidisciplinary team comanagement of surgical patients and clinical outcomes: A systematic review and meta-analysis.
        JAMA Netw Open. 2020; 3: e204088
        • Coster W.J.
        Making the best match: Selecting outcome measures for clinical trials and outcome studies.
        Am J Occup Ther. 2013; 67: 162-170
        • Iberti C.T.
        • Briones A.
        • Gabriel E.
        • Dunn A.S.
        Hospitalist-vascular surgery comanagement: Effects on complications and mortality.
        Hosp Pract (1995). 2016; 44: 233-236
        • Mudge A.M.
        • McRae P.
        • Donovan P.J.
        • Reade M.C.
        Multidisciplinary quality improvement programme for older patients admitted to a vascular surgery ward.
        Intern Med J. 2020; 50: 741-748
        • Powell B.J.
        • Waltz T.J.
        • Chinman M.J.
        • et al.
        A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project.
        Implement Sci. 2015; 10: 21
        • Jasper E.V.
        • Dhesi J.K.
        • Partridge J.S.
        • Sevdalis N.
        Scaling up perioperative medicine for older people undergoing surgery (POPS) services; use of a logic model approach.
        Clin Med (Lond). 2019; 19: 478-484
        • Hope C.
        • Estrada N.
        • Weir C.
        • et al.
        Documentation of delirium in the VA electronic health record.
        BMC Res Notes. 2014; 7: 208