August 9, 2019

Older patients are increasingly undergoing risky surgeries. How can hospitals keep them safe?

Daily Briefing

    The American College of Surgeons recently rolled out new standards for hospitals that aim to improve surgical outcomes for older patients who increasingly are undergoing complex surgeries that in the past may have been considered too dangerous for this patient population, Paula Span reports for the New York Times.

    Ready-to-present slides: General surgery market trends for 2019

    Why older patients are increasingly undergoing surgery

    Clifford Ko, a colorectal surgeon at the University of California, Los Angeles and one of the co-leaders of the American College of Surgeon's Coalition for Quality in Geriatric Surgery, noted he'd recently performed a complex surgery on an 86-year-old patient with rectal cancer.

    "Ten years ago, I'd think, 'My god, can this person even survive the operating room?'" he said. "Now, it's increasingly common to see octogenarians for these types of operations."

    In fact, Span reports, patients ages 65 and older account for 40% of patients receiving surgery in hospitals and potentially more than 50% of all surgeries, despite accounting for about 16% of the U.S. population. And those proportions are expected to increase as the population ages, Span writes.

    What happens to older patients after surgery

    As the number of geriatric patients seeking complex surgery grows, the Coalition for Quality in Geriatric Surgery has kept track of the outcomes, and "[p]erhaps unsurprisingly, older surgical patients often fare worse than younger ones," Span writes.

    One study that analyzed the results of nonemergency surgery in adults over 65 found that complications and mortality increased as the patients got older. Length of stay often did as well.

    A different study found that patients in their 80s who undergo complex surgery for esophageal, pancreatic, or lung cancer have higher mortality rates than patients ages 65 to 69.

    A number of factors explain why older patients are at higher risk for mortality after surgery, Span reports. For one, it's not uncommon for them to have chronic health problems, and to be taking more than one medication to treat those ailments. On top of that, the hospital itself presents a risk for infection and loss of mobility "after days in bed," Span writes.

    Clinicians use language that 'doesn't really describe the experience'

    Further, the older the patient gets, the more likely there is to be miscommunication about the potential complications involved in a procedure as well as the patients' end-of-life plans, according to Span.

    One 77-year-old patient, who had multiple health complications and an aortic aneurysm, decided to undergo surgery after her aneurysm began bleeding.

    Gretchen Schwarze, a vascular surgeon at University of Wisconsin, told the patient that her odds of surviving the surgery were about 50% and that she could opt for a palliative approach for increased comfort, but the woman went forward with the surgery anyway.

    Now, Schwarze said she realizes that "the kind of language we use to explain surgery doesn't really describe the experience," she said.

    The woman went to the ICU after surgery, suffered cardiac arrest, then underwent another operation before being returning to the ICU. The next day the surgical team was "thrilled" by her progress, saying "'Wow, she's doing great,'" Schwarze said.

    It wasn't until the patient's family visited that Schwarze learned that the patient—who was breathing through a tube and unable to open her eyes, speak, or squeeze a hand—feared life support and the possibility of ending up in a nursing home, Span reports. 

    Ko said, "How we talk to them, how we care for them, their outcomes—there's a lot of opportunity to do better."

    A new care standard

    With cases like this in mind, the American College of Surgeon's Coalition for Quality in Geriatric Surgery last month announced a new geriatric surgery verification program that sets 30 standards hospitals should meet to improve outcomes for geriatric patients, Span reports. The list is broad and touches on everything from staffing changes to physical changes, such as "geriatric-friendly" rooms.

    Hospitals that participate in the program will screen geriatric patients for multiple "vulnerabilities" that may put them at risk for mortality or surgery complications, including advanced age, malnutrition, impaired mobility, and cognitive problems, according to Span.

    However, many of the standards stress changes in communication rather than physical or infrastructure changes, Span reports. For instance, the standards call for helping patients truly understand the risks of a procedure as well as alternatives and that doctors understand patients' desires.

    As of June, the verification program was being piloted at eight hospitals in the United States, and the coalition hopes 100 of the more than 4,500 community hospitals that perform adult surgery in the United States will apply in the first year. Hospitals can apply for verification this October (Span, New York Times, 6/7).

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