Cost-effectiveness Analysis of the Elder-Friendly Approaches to the Surgical Environment (EASE) Intervention for Emergency Abdominal Surgical Care of Adults Aged 65 Years and Older

Abstract

IMPORTANCE The Elder-Friendly Approaches to the Surgical Environment (EASE) initiative is a novel approach to acute surgical care for elderly patients. OBJECTIVE To determine the cost-effectiveness of EASE. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation from the perspective of the health care system was conducted as part of the controlled before-and-after EASE study at 2 tertiary care centers, the University of Alberta Hospital and Foothills Medical Centre. Participants included elderly adults (aged Ն65 years) admitted for emergency abdominal surgery between 2014 and 2017. Data were analyzed from April 2018 to February 2019. MAIN OUTCOMES AND MEASURES Data were captured at both control and intervention sites before and after implementation of the EASE intervention. Resource use was captured over 6 months of follow-up and was converted to costs. Utility was measured with the EuroQol Five-Dimensions Three-Levels instrument at 6 weeks and 6 months of follow-up. The differences-indifferences method was used to estimate the association of the intervention with cost and qualityadjusted life-years. For a subset of participants, self-reported out-of-pocket health care costs were collected using the Resource Use Inventory at 6 months. RESULTS A total of 675 participants were included (mean [SD] age, 75.3 [7.9] years; 333 women [49.3%]), 289 in the intervention group and 386 in the control group. The mean (SD) cost per control

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

“…Another recent study using a proactive approach for patients over 65 years presenting for emergency general surgery with integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices, promotion of patient-oriented rehabilitation, and early discharge planning found a significant reduction in mortality, length of stay and discharge to a higher level of care [ 95 ]. Proactive management of these frail patients may also decrease the costs of care [ 97 , 98 ]. At present the evidence indicates that most older emergency laparotomy patients are not reliably assessed for frailty nor co-managed with a care of the elderly team [ 17 ].…”

Patient reported outcomes in an elder-friendly surgical environment: Prospective, controlled before-after study

“…Patient satisfaction at six weeks remained high at the intervention site, and significantly improved Pre-EASE to Post-EASE at the control site. In combination with the EASE interventions demonstrating the clinical and economic benefits, the stable QOL outcomes and patient satisfaction provides further support for elder-friendly surgical care [ 22 , 23 ].…”

“…The Elder-friendly Approaches to the Surgical Environment (EASE) study was one of the largest studies conducted to assess the benefit of an ACE-style model of care in an emergency general surgical population. The EASE study demonstrated improved clinical and economic benefit [ 22 , 23 ]. Recognizing that surgery has significant implications for patients’ nutrition and QOL, as a secondary outcome of the EASE study, we assessed post-discharge patient reported outcomes with the hypothesis that this integrated care will confer a benefit for QOL and patient satisfaction.…”

Sharing the helm: medical co‐management for the older surgical patient

“…27 These findings have informed quality improvement efforts in other vulnerable emergency surgical patients including general surgery, 28,29 emergency laparotomy 2,30 and vascular surgery. 31 Collaborative care models have shown better care coordination, 29,31 decreased complications including delirium and functional decline, 31,32 shorter hospital stays 31,32 and potential cost savings 33 . Observational data from the National Emergency Laparotomy Audit (NELA) in the United Kingdom (UK) show that postoperative geriatrician review is associated with lower mortality in older emergency laparotomy patients, 34,35 while meta-analyses of studies of co-management of surgical patients by geriatricians 36 or general physicians 37 suggest that mortality benefits accrue in models including a multidisciplinary team in addition to the medical specialist.…”

“…And finally, there is the important practical challenge of resourcing, including availability of a skilled medical and multidisciplinary workforce, and financial remuneration and costs of establishing a perioperative medicine service within surgery. The evidence to support the cost saving of co‐management models is mixed, 33,46 but it is hard to measure cost savings of the harm that never happened from a procedure that never occurred. Health services receive funding based on activity, 51 but teamwork, collaboration and long‐term patient outcomes have rarely been incentivized.…”