The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the American College of Surgeons (ACS) and 58 other stakeholder organizations with the support of The John A. Hartford Foundation, has released the first comprehensive set of hospital-level surgical care standards for older adults. The standards have been published online in the Annals of Surgery ahead of print publication in a report titled “Hospital standards to promote optimal surgical care of the older adult,” available on the Annals of Surgery website.
These preliminary standards reflect the shift toward interdisciplinary care of surgical patients, while taking into account the unique physiological changes related to aging and chronic diseases that can sometimes leave older surgical patients at risk for postoperative complications.
“More older people at increasingly advanced ages are undergoing surgery, and it is critical that we move the evidence we have about good surgical care for this population into practice. These preliminary standards put a focus on outcomes that really matter to older people and their families, and are a monumental step forward. We are proud to support and partner with the American College of Surgeons on this important work,” said Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation.
Developing the framework
Since its formation in 2015, the CQGS has been working to develop a national framework to improve the quality of surgical care for older adults. Because no such infrastructure exists at present, geriatric surgical care is often delivered in a fractured health care system that is not readily prepared to address an aging population. And yet, this vulnerable population is on the rise—more than 40 million adults ages 65 years and older are living in the U.S. today, and that number is projected to grow to 24 percent of the population by 2060 from 15 percent in 2015, according to the U.S. Census Bureau.1 Further, the Centers for Disease Control and Prevention reports that of the 51.4 million procedures performed in 2010, 38 percent of the patients were 65 years and older.2
The new geriatric surgical care standards build on existing quality indicators, National Quality Forum-endorsed quality measures, and previous work by the ACS, American Geriatrics Society, and The John A. Hartford Foundation, which have previously collaborated to develop two sets of perioperative care guidelines.3,4
However, standards of care differ from guidelines. “Guidelines are usually recommendations based on an evidence review and typically issued by professional societies or other expert panels,” explained Julia Berian, MD, lead author and an ACS Clinical Scholar. “Standards, as they exist in ACS Quality Programs, are more than recommendations—they are elevated to the level of care practices that are expected to be completed, and then verified by peer reviewers who evaluate whether the standards are being met and practiced appropriately in a clinical setting.”
For the Annals study, an initial 2015 CQGS stakeholders conference identified care gaps for older surgical patients and ideal future solutions across four areas: goals and decision making, perioperative optimization, clinical perioperative care, and care transitions. These categories provided structure for the preliminary standards. Through the use of a modified RAND-University of California, Los Angeles, Appropriateness Methodology, stakeholders rated these candidate standards during a second stakeholders’ conference in May 2016.
“The methodology used is a validated technique for putting together the best level of published evidence with the input of thought leaders in the field, giving us a useful combination of efficacy, effectiveness, feasibility, and implementation,” said Clifford Y. Ko, MD, MS, MSHS, FACS, study co-author, CQGS Co-Principal Investigator, and Director of the ACS Division of Research and Optimal Patient Care and the ACS National Surgical Quality Improvement Program®.
The preliminary standards were divided into the following four sections:
- Continuum of care, encompassing patient-centered goals and decision making, perioperative optimization, and transitions of care
- Clinical care, encompassing the phases of immediately preoperative, intraoperative, and postoperative care
- Program management, encompassing personnel and committee structure of a geriatric surgery program, and credentialing and education standards for hospital personnel who care for older surgical patients
- Patient outcomes and follow-up
CQGS stakeholders reviewed and rated the 308 proposed standards of care for both validity and feasibility. The stakeholders rated 306 of 308 (99 percent) of the standards as valid to improve the quality of geriatric surgery, and 94 percent of the standards (290 out of 309) as feasible for implementation.
Authors wrote, “The widespread agreement on the validity of these comprehensive standards indicates that we know what high-quality care for older adult surgical patients should look like.” However, in terms of feasibility, they found that “some standards were perceived to require high resources, and, therefore, the feasibility of implementation across hospitals that vary in size, location, and teaching status remains uncertain.”
Although the end goal is to implement the CQGS standards in a formalized verification and quality improvement program through the ACS, there is still work to be done. The preliminary standards are currently undergoing a two-phased pilot process.
“Now that we’ve confirmed what high-quality surgical care for older adults should look like, we’re ready to evaluate how these standards will work in a hospital environment. This is an important aspect of the project, and the feedback portion from hospitals is vitally important,” said Ronnie Rosenthal, MD, MS, FACS, CQGS Co-Principal Investigator.
The alpha pilot phase launched in January and is now in its final stages. Fifteen end-user hospitals reviewed the standards to provide feedback to CQGS on anticipated challenges in meeting the standards, identifying unclear standards, and gaining insight on the value of implementing these standards in their hospital environment and with their patients.
“Although feasibility of implementation may be a challenge for some hospitals, the CQGS continues to explore ways to make these standards flexible across different hospital settings, sizes, and resource levels. Our alpha pilot will elicit real-world feedback from frontline hospitals and providers about these standards,” Dr. Berian said.
A beta pilot phase will follow in late 2017, and will engage six hospitals to actually implement the standards for older surgical patients.
Once the pilot phases have been completed and a national verification program is available, participating hospitals will make the commitment to ensure that geriatric surgical quality is interconnected with a hospital’s quality and safety culture.
This program shows great potential to transform surgery for older adults across the nation, according to Dr. Ko. “As opposed to many of the outstanding clinically based quality improvement programs that target a specific disease, this program targets an enormous and increasing segment of our population,” he said. “To that end, except for pediatric hospitals, this program has the potential to capture all or nearly all hospitals in the country. But to truly have these standards widely accepted, it will be the local health care providers and facilities that will need to understand the importance of the resources and processes needed to optimally care for geriatric surgical patients.”
- U.S. Census Bureau. 2014 national population projections summary tables. Table 6: Percent distribution of the projected population by sex and selected age groups for the U.S.: 2015 to 2060. Available at: www.census.gov/population/projections/data/national/2014/summarytables.html. Accessed May 9, 2017.
- Centers for Disease Control and Prevention. Number of discharges from short-stay hospitals, by first-listed diagnosis and age: United States, 2010. Available at: www.cdc.gov/nchs/data/nhds/3firstlisted/2010first3_numberage.pdf. Accessed May 9, 2017.
- Mohanty S, Rosenthal RA, Russell MM, et al. Optimal perioperative management of the geriatric patient: A best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947. Accessed April 21, 2017.
- Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. Accessed April 21, 2017.