More than one-third of all inpatient operations in the U.S. involve patients ages 65 and older.1 In 2010, the cost of hospitalization with an operating room (OR) principal procedure for this patient population was $72 billion.2 Because surgical care for older adults is common and consumes enormous amounts of resources, understanding the relevant outcomes and their key determinants for geriatric patients is vital.
The American College of Surgeons (ACS) National Surgical Quality Improvement Program (ACS NSQIP®) is the preeminent outcomes-based program designed to measure and improve the quality of surgical care in the U.S. ACS NSQIP was developed with the goal of providing risk-adjusted surgical outcomes data for adults. In 2010, ACS NSQIP introduced the first National Quality Forum (NQF)-endorsed measure to track surgical outcomes in patients greater than 65 years of age. The geriatric measure uses standard ACS NSQIP risk variables to track traditional patient- and procedure-adjusted surgical outcomes, such as postoperative complications and 30-day mortality. Although this measure has proven to be a significant step forward in improving care in this vulnerable population, recent literature suggests that standard risk factors and traditional outcomes may not provide a complete enough picture through which to focus improvement strategies targeting older surgical patients.
At the 2011 ACS NSQIP National Conference in Boston, MA, David B. Hoyt, MD, FACS, Executive Director of the College, moderated a plenary session to emphasize the need to “achieve optimum surgical care” in a variety of specific areas, including geriatrics. It was clear from the audience response that many hospital systems from across the U.S. and Canada shared the challenge of understanding what constitutes “optimum” outcomes in older patients and how to achieve these results.
Development of the pilot project
With the obvious need for more data, ACS NSQIP and the ACS Geriatric Surgery Task Force worked together to determine how these data could be collected and analyzed by forming a ACS NSQIP Geriatric Surgery Pilot Project. The pilot project is predicated upon two goals: (1) to determine if the inclusion of geriatric-specific preoperative variables and outcome measures in the existing ACS NSQIP models will add to our ability to more accurately predict relevant outcomes, and (2) to provide a platform for introducing new interventions designed to improve these outcomes.
Participant hospitals were recruited from among task force member institutions and at a follow-up geriatric breakout session at the 2013 ACS NSQIP National Conference in San Diego, CA. Representatives of 23 hospitals, including academic centers and community-based systems from the U.S. and Canada, participated in the meeting.
Choosing the variables
Candidate variables were reviewed by task force members and ACS NSQIP staff primarily for relevance and for ease of extraction from the medical record. To be relevant, the new preoperative variable set needed to address characteristics unique to the older adult. In contrast to younger adults (<65 years old) in whom surgical risk is estimated by summing comorbid conditions, the presence of frailty is rapidly emerging as a primary factor that defines increased risk in the older surgical patient.3,4
Frailty is defined as “a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems…causing vulnerability to adverse outcomes.”5 Although there are many different ways of identifying a frail individual, most characteristics of frailty are not routinely assessed in clinical practice. Consideration was given to those variables that could best describe the frail state, such as evidence of impaired cognition, functional dependence, and reduced mobility.
The new outcome variables are needed in order to capture the outcomes that are common and important to older patients, including postoperative delirium and functional decline. Postoperative delirium occurs in approximately one-half of older patients undergoing major operations and is associated with increased rates of all other major complications, a need for institutional discharge, and death. Interventions to decrease postoperative delirium do exist, and efforts are under way to establish evidence-based guidelines. To date, however, delirium is not routinely recognized as a surgical complication in older adults and, therefore, is not tracked.
Functional decline following surgery is often more of a concern to the older surgical patient than the risk of mortality, but because it is rarely measured, there is a lack of data allowing surgeons to counsel older patients on its risks. In addition, ACS NSQIP currently lacks a robust method for identifying patients who are undergoing surgery for palliative intent, for whom the risk may not be well captured by traditional variables (palliative care is a more common primary objective in geriatric surgery compared with surgery on younger patients). The outcome variables for the ACS NSQIP Geriatric Surgery Pilot Project were chosen to specifically identify changes in postoperative cognition, functional decline, and a need for transition to palliative care.
Once appropriate variables were selected, the Clinical Support team from ACS NSQIP developed strict definitions of these variables, in a manner consistent with all of the other variables in the program. The variables and definitions were then reviewed a final time by task force members before commencement of data collection.
Current status of the pilot project
The ACS NSQIP Geriatric Surgery Pilot Project includes 23 hospitals, and features 14 new variables specifically chosen for their relevance to geriatric surgical patients (see table). ACS NSQIP staff members including Matt Fordham, Project Coordinator, ACS NSQIP; James Wadzinski, ACS NSQIP Director of Operations; Melissa Latus, ACS NSQIP Clinical Support Services Manager; and Amy Hart, ACS NSQIP Product Operations Manager, have provided invaluable assistance to making the pilot project a success, as well as Sanjay Mohanty, MD, one of the ACS Clinical Scholars in Residence (2013–2015), who is analyzing the data. Data collection began on January 1, 2014, and an interim analysis of the project’s efforts was presented at the ACS NSQIP National Conference in New York, NY, in July. Both the viability of data collection and the ability of these new variables to provide additional insight into the care of geriatric patients will be assessed.
New Variables Collected by the ACS NSQIP Geriatric Pilot Project
|Intent of variable (definition)|
|Origin from home with support||To determine baseline functional status (lives alone at home, lives with support in home, origin status not from home)|
|Use of mobility aid||To quantify baseline mobility (uses a walking aid—yes/no)|
|History of prior falls||To define the presence of a geriatric syndrome prior to admission (prior fall—yes/no)|
|History of dementia||To determine baseline cognition (history of dementia—yes/no)|
|Competency status on admission||To define significant cognitive impairment (consent signed by patient or by surrogate—yes/no)|
|Palliative care on admission||To identify patients admitted from palliative care or hospice (from palliative care/hospice—yes/no)|
|Intent of variable (definition)|
|Postoperative pressure ulcer||To define the presence of a geriatric syndrome at discharge (a pressure ulcer is present at discharge; did it occur during the hospital stay—yes/no)|
|Postoperative delirium||To define the presence of a geriatric syndrome during the hospital stay (delirium is present if there are one or more episodes of acute confusion during hospitalization—yes/no)|
|Do not resuscitate (DNR) order during hospitalization||To capture changes in DNR status during the hospital stay (was there a new DNR order during hospitalization—yes/no)|
|Palliative care consult||To understand treatment goals of patients with short life expectancy (palliative care consult obtained during hospitalization or patient made comfort care—yes/no)|
|Discharge functional health status||To determine functional status at discharge (ability to perform activities of daily living at discharge—independent/partially dependent/dependent)|
|Fall risk on discharge||To quantify mobility at discharge (define fall risk at time of discharge—high/low)|
|Need of mobility aid on discharge||To understand a patient’s mobility at discharge (new use of mobility aid walker/cane at time of discharge—yes/no)|
|Discharge with/without services||To capture care needs at discharge (home alone with self-care, home alone with skilled care, home with support and self-care, home with support and skilled care)|
The ultimate goal of this pilot project is to evaluate specific geriatric variables for incorporation into the ACS NSQIP set of essential variables collected by all participating hospitals. These variables may then be used to measure the effectiveness of interventions designed to mitigate geriatric-specific surgical risks and improve outcomes.
- Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. National Health Statistics Reports. U.S. Department of Health and Human Services. October 26, 2010. Accessed February 12, 2014.
- U.S. Department of Health and Human Services. Health. United States, 2012. Accessed February 12, 2014.
- Robinson TN, Eiseman B, Wallace JI, et al. Redefining geriatric preoperative assessment using frailty, disability, and co-morbidity. Ann Surg. 2009;250(3):449-455.
- Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908.
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.