Publications

OBJECTIVES

To evaluate the association of frailty, a measure of diminished physiological reserve, with both major and minor surgical complications among patients undergoing urological surgery.

MATERIALS AND METHODS

Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2007 to 2013, we identified all urological cases that appeared > 1000 times in the dataset among patients aged ≥40 years. Frailty was measured using the NSQIP frailty index (FI), a validated measure that includes 11 impairments, such as decreased functional status and impaired sensorium. We created multivariable logistic regression models using the NSQIP FI to assess major and minor complications after surgery.

RESULTS

We identified 95 108 urological cases representing 21 urological procedures. The average frequency of complications per individual was 11.7%, with the most common complications being hospital readmission (6.2%), blood transfusion (4.6%) and urinary tract infection (3.1%). Major and minor complications increased with increasing NSQIP FI. Frailty remained strongly associated with complications after adjustment for year, age, race, smoking status and method of anaesthesia (adjusted odds ratio 1.74 [95% confidence interval 1.64, 1.85] for an NSQIP FI ≥0.18). Increasing NSQIP FI was associated with increasing frequency of complications within age groups (by decade) up to age 81 years and across most procedures.

CONCLUSION

Frailty strongly correlates with risk of postoperative complications among patients undergoing urological surgery. This finding is true within most age groups and across most urological procedures.

BACKGROUND

As the population ages, an increasing number of older patients are undergoing major surgery. We examined the impact of advanced age on outcomes following major gastrointestinal cancer surgery in an era of improved surgical outcomes.

MATERIALS AND METHODS

This was a population-based, retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We evaluated patients undergoing major abdominal gastrointestinal cancer surgery from 2005-2012. Multivariable logistic regression was performed to determine the independent effect of advanced age on outcomes. Our primary outcome was 30-d mortality, and our secondary outcomes were 30-d major postoperative adverse events, discharge disposition, length of stay, reoperation, and readmission.

RESULTS

Elderly (≥65 y) patients were twice as likely to have multiple comorbidities as those <65 y but prevalence of comorbidities was similar across all older age groups. Mortality increased with age across all procedures (P < 0.05). The risk of advanced age on mortality was highest in hepatectomy (odds ratio = 5.17, 95% confidence interval = 2.19-12.20) and that for major postoperative adverse events was highest in proctectomy (odds ratio = 2.32, 95% confidence interval = 1.53-3.52). Patients were more likely to be discharged to an institutional care facility as age increased across all procedures (P < 0.01).

CONCLUSIONS

Despite being highly selected for surgery, elderly patients undergoing major gastrointestinal cancer surgery have substantially worse postoperative outcomes than younger patients (<65 y). The risk of age on postoperative outcomes was present across all operations but had its highest association with liver and rectal cancer resections.

As the world's aging population grows, the surgical population is increasingly made up of older adults. Due to changes in physiologic function and increasing comorbidity burden, older adults are at increased risk of morbidity, mortality, and functional decline after surgery. In addition, decision to undergo surgery for the older adult may be based on the postoperative functional outcome rather than survival. Although few studies have evaluated an older adult's function as a postoperative outcome, surgeons are becoming increasingly aware of the importance of maintaining or regaining function in an older patient. Interventions to improve postoperative functional outcomes are being developed and show promising results. This review discusses existing literature on postoperative functional outcomes in older adults and recently developed interventions.

BACKGROUND

Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons.

OBJECTIVE

The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons.

DESIGN

This was a prospective cohort study.

SETTINGS

Patients and surgeons were enrolled from 3 colorectal surgery clinics.

PATIENTS

Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected.

INTERVENTIONS

Patients used a multilingual decision aid before meeting with the surgeon.

MAIN OUTCOME MEASURES

We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid.

RESULTS

Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients' knowledge scores improved by 39% (p < 0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid.

LIMITATIONS

The study included a small sample with no comparison group.

CONCLUSIONS

A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.

OBJECTIVE

To evaluate the association between frailty and postoperative discharge destination after different types of commonly performed urologic procedures in older patients.

MATERIALS AND METHODS

Using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2011 to 2013, we identified commonly performed inpatient urologic procedures among patients aged 65 and older. We then assessed the effect of frailty, measured by the NSQIP Frailty Index (NSQIP-FI), on discharge to a skilled or assisted living facility using logistic regression and assessed the heterogeneity of this effect across procedures using 2-level random effects modeling.

RESULTS

Overall, 1144 out of 20,794 (5.5%) urologic cases, representing 19 different procedures, resulted in discharge to a skilled or assisted living facility. Cystectomy and large transurethral resection of bladder tumor had the highest percentage (16.3%). Twenty-five percent of patients undergoing urology procedures were frail (NSQIP-FI 0.18+), including 9.8% of patients discharged to a facility. Even after adjustment for year, age, race, type of anesthesia, smoking status, recent weight loss, and whether or not the procedure was elective, frailty was strongly associated with discharge to a facility (adjusted odds ratio 3.1 [96% confidence interval 2.5, 3.8] for NSQIP-FI 0.18+ compared to NSQIP FI 0). This finding was consistent across most procedures of varying complexity with an overall effect of odds ratio 1.6 (95% confidence interval 1.5, 2.0).

CONCLUSION

Increasing frailty is associated with discharge to a skilled or assisted living facility across most inpatient urologic procedures evaluated, regardless of complexity. This information is important for preoperative counseling with patients undergoing urologic surgery.

OBJECTIVES

Primary objective: to use advanced nonparametric techniques to determine risk factors for readmission after colorectal cancer surgery in elderly adults.

SECONDARY OBJECTIVE

to compare this methodology with traditional parametric methods.

DESIGN

Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), nonparametric techniques were used to evaluate the risk of readmission in elderly adults undergoing surgery for colorectal cancer in 2011 and 2012.

SETTING

More than 200 hospitals participating in the NSQIP database.

PARTICIPANTS

Individuals aged 65 and older who underwent surgery for colorectal cancer in 2011 and 2012 (N = 2,117).

MEASUREMENTS

Age-stratified robust nonparametric predictive model (classification and regression tree (CART) analysis) of 30-day readmission for elderly adults undergoing surgery for colorectal cancer.

RESULTS

Recent chemotherapy was the most important predictor of readmission in participants aged 65 to 74, with 20% of those with recent chemotherapy and 11% of with no recent chemotherapy being readmitted. Participants aged 75 to 84 who had recently undergone chemotherapy had a readmission rate of 23%, whereas those with no chemotherapy had a readmission rate of 9%. Being underweight was the greatest predictor of readmission (30%) in participants aged 85 and older. These methods were found to be more robust than traditional logistic regression.

CONCLUSION

Specific age-related preoperative factors help predict readmission in elderly adults undergoing colorectal cancer surgery. Results of the nonparametric CART analysis are better than traditional regression analysis and help physicians to clinically stratify based on age. This model may help identify individuals in whom intervention may be helpful in reducing readmission after surgery.