Improving quality in geriatric surgery: A blueprint from the American College of Surgeons

Surgery in the U.S. is undergoing a paradigm shift, with safety, quality, and patient-centered care now driving care delivery processes and payment. As a result of the passage of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act, major changes are being proposed as part of a new Quality Payment Program (QPP), which will be implemented in 2017 by the Centers for Medicare & Medicaid Services (CMS) with the goal of aligning payment with high-quality care.¹

At the same time, the population is rapidly aging, placing significant stress on the health care system. Older adults comprise a growing portion of the surgical population and affect all heath care settings, including large and small hospitals, urban and rural locales, and university and community facilities. According to the U.S. Census Bureau, the proportion of adults ages 65 years and older is projected to grow from 15 percent in 2015 to 24 percent of the population in 2060.² This rapidly growing segment of the population constitutes a large part of the medical and surgical care provided in the U.S. Patients older than age 65 account for approximately 38 percent of hospital discharges in 2010, according to data from the National Hospital Discharge Survey.³ A total of 51.4 million procedures were performed across the U.S. in 2010, with 19.2 million of those operations performed on patients ages 65 and older.³ The aging of the population will lead to a significant increase in the demand for surgical services, and surgeons must develop strategies to maintain high-quality and patient-centered care despite an increased workload.^4,5

Furthermore, physiological changes related to aging and chronic disease leave the older surgical patient at risk for postoperative complications, functional decline, loss of independence, and other untoward outcomes that may affect quality of life.^6-11 More attention needs to be paid to this vulnerable population using both resources and standardized processes of care to facilitate improved outcomes for older patients who need surgical care.¹²

New model for surgical care

Although the role of the surgeon is usually focused on the technical activities in the operating room, the complex needs of an elderly surgical population require a broader perspective. Increased attention to preoperative risk assessment, explicit communication with the patient and family regarding goals of care as well as anticipated functional outcomes, and an emphasis on postoperative rehabilitation must be as much a part of the job as the execution of the technical aspects of surgery. In addition, due to advances in surgical technique, anesthesia, and postoperative care, surgical procedures are safer and inhospital mortality rates are low. For older adults, the new focus on patient safety and quality no longer revolves solely around surgical morbidity and mortality; patient-centered issues have now gained importance, including quality of life, maintenance of independence, and return to preoperative level of functioning. A patient’s personal health care goals become increasingly important for older, complex patients who may lack the physiologic reserves of younger adults and often prioritize quality over quantity of life when making health care decisions.¹³

The combination of these forces created demand for the development of a new model for surgical care of older adults to ensure the provision of efficient and optimal care for this vulnerable population. The National Academy of Medicine defines health care quality as the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. It is clear that care for the elderly surgical patient must fulfill each of these domains. The paradigm shift in surgery will affect not only how the health care system provides care for elderly surgical patients, but also how surgeons are trained. The American College of Surgeons (ACS) has been a leader in surgical quality improvement and surgeon education through its quality programs in specialties such as trauma, cancer, and bariatrics. The time has come to take on the same role for geriatric surgery.

ACS leadership in surgical quality

Throughout its more than 100-year history, the ACS has been dedicated to promoting high-quality care. The College now has extensive experience in the development and verification of quality improvement (QI) programs across various multidisciplinary surgical conditions or populations, including trauma, cancer, and bariatric surgery. These programs are based on four principles:

• Set the standards, individualized by patient and supported by research
• Provide the right infrastructure, including staffing composition and equipment
• Measure the outcomes using the right data
• Verify that the standards, the infrastructure, and the data are meeting expectations

At present, more than 3,000 hospitals are accredited through one or more ACS Quality Programs.

Building on the strength of the College’s Quality Programs, the ACS partnered with the John A. Hartford Foundation to develop a geriatric surgery QI program based on these same principles.¹⁴ The Coalition for Quality in Geriatric Surgery (CQGS) Project is a four-year initiative to define the processes, resources, and infrastructures necessary to provide optimal care of the older adult surgical patient. The project aims to guide improvement for all hospitals, regardless of size, location, or teaching status. The CQGS comprises a nine-member core development team, including surgeons, nurses, and geriatricians with expertise in geriatric surgery, ACS staff, and research scholars. The CQGS is supported by a diverse group of more than 50 stakeholder organizations. The seven overarching goals of the CQGS Project are as follows:

• Set the standards
• Engage key stakeholders
• Develop measures that matter
• Develop the verification process to ensure delivery of high-quality care
• Educate patients and providers
• Pilot the program
• Launch the Geriatric Surgery Quality Campaign

The evidence and expert-based standards will provide a framework that will be scalable and generalizable to all facilities that perform surgical care for older adults. The standards will ultimately form the foundation for the development of age-appropriate and patient-centered outcome measures, as well as the verification program, which will not only audit adherence to the standards, but will define the processes for assuring continuous quality improvement and patient safety.

Improving quality of care for older adults

The health care community has developed many tools to support the evaluation and improvement of care of the geriatric surgical patient. Examples include guidelines,^15,16 quality indicators,¹⁷ National Quality Forum-endorsed quality measures on elderly surgery outcomes, and products developed from the ACS National Surgical Quality Improvement Program (ACS NSQIP^®), including the Surgical Risk Calculator (see related article in this issue); a data registry with geriatric-specific variables such as postoperative delirium and functional status at hospital discharge; and consortia/collaboratives on geriatric surgery.^15-18 The next logical step is to assemble these tools together into a feasible and generalizable set of standards that will provide a multi-layered approach to the optimal care of the older surgical patient.

The issues surrounding quality of care for the elderly patient differ from those affecting younger patients. First, the degree of comorbid disease burden is higher in elderly patients, requiring closer attention to preoperative optimization of cardiovascular, pulmonary, renal, and endocrine status.

Second, the assessment of geriatric syndromes, including cognitive impairment, malnutrition, and risk of falls or pressure ulcer development, should be considered a standard part of the routine preoperative evaluation. Assessment of baseline cognitive, nutritional, and functional status will not only guide the perioperative care of the elderly patient, but may affect the patient-provider discussions regarding aggressiveness of surgical intervention as well as provide a baseline level for comparison of these measures upon discharge from the hospital.

Third, the quality of care for elderly surgical patients is more complex due to diminished physiologic reserves, which affects the ability to withstand perioperative stress. Therefore, prevention of perioperative morbidity (delirium, infection, deep venous thrombosis, myocardial ischemia, and so on) becomes the emphasis for this vulnerable population.

Finally, patient-provider discussions become increasingly important to define the goals of surgical intervention as well as the extent of life-sustaining interventions in the event of untoward postoperative complications. The goals of care may range from a decision not to pursue surgical intervention, to palliation of malignant bowel obstruction, to curative colorectal cancer resection.

Traditional outcomes measures in surgery include morbidity and mortality; however, additional outcomes measures are appropriate in the elderly population given the emphasis on quality of life rather than on prolongation of life. The typical definition of postoperative morbidity must be expanded to include postoperative events more commonly seen in the elderly population, including episodes of postoperative delirium, in-hospital falls, development of a pressure ulcer, and maintenance versus decline of functional or cognitive status. A primary outcome of interest after surgical intervention in the elderly population should be the ability to return to the previous living environment, as well as the level of function before surgery, which may require looking beyond the traditional end point of 30 days after surgery. Therefore, the location of discharge after surgery (for example, home versus skilled nursing facility), the functional status as measured by activities of daily living, and ambulation become important outcomes for the elderly patient undergoing surgery.

What have we done so far?

The discipline of geriatrics is becoming an important part of the care on the surgical ward, which has implications for how to train, teach, and restructure the surgical unit for both surgeons as well as other health care professionals. Internal medicine has made changes in the accreditation process of residency programs to ensure that the emphasis on quality of care also is translated into quality of training. In this regard, many potential tools are available to effect policy changes within the field of surgery and improve the care for elderly surgical patients.

It is important to embrace the shift toward interdisciplinary care of surgical patients. In the traditional surgical model, the surgeon rounds on their patients twice a day while the nursing staff is primarily trained to manage the technical aspects of the patient’s postoperative recovery. A new model may be required for elderly surgical care, more in line with a team approach and integration of providers, including surgeons, anesthesiologists, geriatricians, general internists, medical specialists, and rehabilitation specialists, as well as nursing, physical/occupational therapists, speech pathologists, nutritionists, and care transition professionals (such as social work, case management, and discharge planning personnel). The team approach is central to the success of this model because the elderly surgical patient often brings an amalgam of both medical and surgical comorbidities, in addition to a range of capabilities with respect to cognition, ambulation, psychosocial needs, and degree of independent self-care. No single provider can maintain the optimal care needed for an elderly patient undergoing a major surgical procedure because the cross-cutting issues of nutrition, cognition, rehabilitation, management of comorbid disease burden, and postoperative surgical care require coordination among multiple health care providers. Furthermore, multidisciplinary care for older adults is critical across the phases of care from the preoperative assessment, to postoperative recovery, to discharge from the hospital.

A second tool that may be used to address the unique issues of elderly surgical care is best practice guidelines. In 2012, the ACS and the American Geriatrics Society (AGS) entered a partnership with the John A. Hartford Foundation to synthesize the available evidence on preoperative care for elderly patients. This collaboration resulted in the development of the 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.”¹⁵ This protocol provides a clear framework for conducting preoperative evaluation of geriatric surgical patients, emphasizing the importance of cognitive assessment, depression and substance abuse screening, cardiac and pulmonary evaluation, documentation of functional status and history of falls, evaluation of nutrition status and polypharmacy, and inquiry into the patient’s understanding of treatment goals and expectations.¹⁵

A follow-up set of guidelines detailing best practices for care in the perioperative period (including immediate pre-, intra-, and postoperative phases) was released in 2016.¹⁶ Recommendations range from a purposeful reconsideration of treatment preferences, to modification of perioperative anesthetic medications, to pain management and delirium prevention postoperatively, to the importance of clear discharge instructions and communication with the primary physician during the transition from the hospital to home.

In addition, the John A. Hartford Foundation has supported the development of the AGS clinical practice guideline for postoperative delirium in older adults.¹⁸ This guideline meets the rigorous standards set forth by the Institute of Medicine (now the National Academy of Medicine) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines.¹⁹ Its report provides recommended pharmacologic and non-pharmacologic interventions that should be implemented perioperatively both for the prevention and, if needed, treatment of postoperative delirium in older adults.

ACS NSQIP Geriatric Surgery Pilot Project

Special attention must be paid to geriatric-specific risk factors and outcomes. The ACS NSQIP Geriatric Surgery Pilot Project, launched in 2014, includes 26 hospitals that are collecting data on four important patient-centered domains: cognition, decision making, mobility, and function.²⁰ Within each domain, the pilot collects data on both preoperative and postoperative variables. For example, cognition variables include whether a patient has preoperative cognitive impairment or experiences an episode of postoperative delirium. Similarly, the mobility domain includes information about a history of falls and whether a new mobility aid is required at the time of discharge. Examining changes in mobility, functional status, and discharge destination (home versus facility), the Geriatric Surgery Pilot data may be used to improve understanding of patient-centered outcomes. Loss of independence, defined as decline in mobility or function or the need for new assistance in the post-discharge living situation, occurred among almost half of older adults postoperatively and was significantly associated with not only readmission, but also death after discharge.⁶ The ACS NSQIP Geriatric Surgery Pilot has now collected geriatric-specific data on more than 25,000 older adults. As these data points become easier to collect, awareness and responsiveness to geriatric-surgery issues will continue to improve. It is clear that quality of care cannot be limited to the immediate hospitalization. The pilot has recently expanded its use of longer-term outcomes and has begun collecting 30-day outcomes of functional status and living location. Future work will aim to incorporate patient-reported outcomes into the ACS NSQIP clinical data registry, which will provide more detailed and granular information to improve surgical decision making and align the care provided with patient goals.

Bringing together all of this groundwork, the CQGS Project seeks to improve the quality of surgical care for older adults, regardless of the hospital’s size, location, or teaching status.¹⁴ The CQGS has engaged more than 50 stakeholder organizations, including groups representing the various surgical disciplines, anesthesia, geriatrics, nursing, social work, pharmacy, patient advocacy, emergency medicine, physical therapy, community resources, advocacy and regulatory organizations, and, perhaps most importantly, patients and families.

Two formal stakeholder meetings occurred in the first year of the project. The goal of the first meeting was to map out the gaps in surgical care against the ideal future state of surgical care for older adults. These goals are represented in Table 1, and have been used to develop recommendations to immediately improve care. In addition, based on the input from the first stakeholder meeting, extensive literature searches, in-person field visits to hospitals across the nation, and targeted input from key stakeholders, 308 preliminary standards were drafted.

At the second stakeholder meeting, these preliminary standards were discussed and rated by the stakeholders for both validity and feasibility using a modification of the RAND/University of California, Los Angeles, Appropriateness Method. The analysis of stakeholder ratings is under way to produce the final set of standards defining the optimal care of the older adult surgical patient across the preoperative, intraoperative, postoperative, and transition to home phases of care.

Table 1. Suggested strategies to improve surgical care of older adults

Steps for improved surgical care of older adults	Action items
Elicit patient goals	Ask separately about the patient’s overall health goals and the patient’s goals specific to the procedure
Perform geriatric risk assessment preoperatively	Examples: Administer the “mini-cog”to assess cognition.21 This exam includes three steps: (1) provide three words for recall, (2) clock drawing, (3) ask patient to recall the three words from step 1. Timed up-and-go test to assess ambulation; includes the time required for patient to stand from a chair, walk three meters or 10 feet, then return to chair and sit down.22,23
Educate health care professionals about geriatric-specific issues	Visit the Coalition for Quality in Geriatric Surgery Project web page to access the Pre- and Peri-Operative Guidelines for Optimal Management of the Geriatric Surgical Patient and to learn more about the CQGS Project
Increase communication across disciplines and phases of care	Engage multidisciplinary care at your hospital: Discuss high-risk older adults at a preoperative conference or enact postoperative multidisciplinary team rounds

The near future

As the CQGS Project continues to evolve, the standards will be finalized and attention will turn toward measurement. The project will soon begin development of a data registry that can track important data elements and outcomes as defined by the standards. The project aims to develop measures that matter to older adults, which may include longer-term outcomes like a return to previous level of functioning. Drawing on the experience of the ACS NSQIP Geriatric Surgery Pilot Project, we will begin to refine patient-centered outcomes in important domains, including cognition, function, mobility, and decision making.

As the payment system shifts in the coming years, many payors, including CMS, will attempt to better align compensation with quality of care. The CQGS Project will provide a streamlined set of standards for processes of care, and a system for data collection and measurement of outcomes that are not only important to providers but also to the patients whom we serve. Furthermore, external peer verification will provide public assurance of the quality of care for older surgical patients. With the newly proposed QPP, the current project has the potential to contribute meaningful quality metrics for surgeons who care for older adults.

Conclusion

The expanding and aging U.S. population has created a growing demand for high-quality care in geriatric surgery. As the population continues to age, the number of elderly patients requiring surgical intervention will continue to increase. Surgeons, geriatricians, internists, and other health care providers need to become more familiar with the complex interdisciplinary issues unique to the growing elderly patient population. It is the vision of the ACS, in partnership with the John A. Hartford Foundation, that the CQGS Project will lead the effort to improve care for every older surgical patient.

References

1. Centers for Medicare & Medicaid Services Quality Payment Program: Delivery system reform, Medicare payment reform and MACRA. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-QPP.html. Accessed September 16, 2016.
2. 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 October 26, 2016.
3. 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 October 26, 2016.
4. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177.
5. Etzioni DA, Liu JH, O’Connell JB, Maggard MA, Ko CY. Elderly patients in surgical workloads: A population-based analysis. Am Surg. 2003;69(11):961-965.
6. Bentrem DJ, Cohen ME, Hynes DM, Ko CY, Bilimoria KY. Identification of specific quality improvement opportunities for the elderly undergoing gastrointestinal surgery. Arch Surg. 2009;144(11):1013-1020.
7. Finlayson E, Zhao S, Boscardin WJ, Fries BE, Landefeld CS, Dudley RA. Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc. 2012;60(5):967-973.
8. Lawrence VA, Hazuda HP, Cornell JE, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg. 2004;199(5):762-772.
9. Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. September 2016. [Epub ahead of print].
10. Mohanty S, Liu Y, Paruch JL, et al. Risk of discharge to postacute care: A patient-centered outcome for the American College Of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. JAMA Surg. 2015;150(5):480-484.
11. Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: Risk factors and outcomes. Ann Surg. 2009;249(1):173-178.
12. Berian JR, Rosenthal RA. Redefining quality of surgical care for the frail elderly. Curr Surg Rep. 2016;4(3):1-11.
13. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066.
14. The Coalition for Quality in Geriatric Surgery Project. American College of Surgeons: Quality Programs. Available at: facs.org/quality-programs/geriatric-coalition. Accessed October 26, 2016.
15. 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.
16. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. 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.
17. McGory ML, Kao KK, Shekelle PG, et al. Developing quality indicators for elderly surgical patients. Ann Surg. 2009;250(2):338-347.
18. 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(1):142-150.
19. U.S. Institute of Medicine. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Graham R. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011.
20. Robinson TN, Rosenthal RA. The ACS NSQIP Geriatric Surgery Pilot Project: Improving care for older surgical patients. Bull Am Coll Surg. 2014;99(10):21-23.
21. Borson S, Scanlan JM, Chen P, Ganguli M. The mini-cog as a screen for dementia: Validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451-1454.
22. Cassel CK. Quality of care and quality of training: A shared vision for internal medicine? Ann Intern Med. 2004;140(11):927-928.
23. Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-148.