Establishing a proactive geriatrician led comprehensive geriatric assessment in older emergency surgery patients: Outcomes of a pilot study

Mason, Matthew; Crees, Amy; Dean, Matthew R.; Bashir, Nahida

doi:10.1111/ijcp.13096

Cited by 14 publications

(12 citation statements)

References 25 publications

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“…We found that geriatricians performed more poorly on cost and quality measures than other PCPs, although a substantial portion of these differences were explained by frailty and neuropsychological conditions, as noted above. This is in contrast to prior literature that has demonstrated generally better outcomes for older adults cared for by geriatricians compared to other clinicians . A potential reason is residual confounding.…”

Section: Discussioncontrasting

confidence: 89%

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

Johnston

Wen

Maddox

2019

J American Geriatrics Society

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See related editorial by Reuben et al. in this issue.OBJECTIVES: Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN: A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING: Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS: Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS: Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS: Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrentyear risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00). CONCLUSION: Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

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Section: Discussioncontrasting

confidence: 89%

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

Johnston

Wen

Maddox

2019

J American Geriatrics Society

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“…Various measures of frailty correlate with various outcomes, including postoperative morbidity and mortality, intensive care survival and postdischarge status . There is some evidence that specialist frailty assessment and treatment teams might alter outcomes . The classification of patients by ASA physical status is similar to their classification by functional frailty.…”

Section: Alternative Scoring Systemsmentioning

confidence: 99%

A review of ASA physical status – historical perspectives and modern developments

2019

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Summary The American Society of Anesthesiologists (ASA) physical status is a tool commonly used to classify a patient's physical fitness before surgery. Since its introduction in 1941 it has undergone very few modifications to improve its reliability and to eliminate subjectivity, despite vast changes in both surgical and anaesthetic technique. We present the history of the ASA physical status and review the literature on its applicability to contemporary anaesthetic practice.

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“…Multidisciplinary teams including geriatricians along with surgeons and anesthesiologists have been established so far in the orthogeriatric field, but there are very scant evidence on the effectiveness of such teams in oncological surgery [43][44][45][46]. Yet, we predict that, once established, such teams will successfully improve many clinical outcomes associated with solid tumor and their surgery, improving patient's functional status and quality of life.…”

Section: The Geriatrician's Clinical Standpointmentioning

confidence: 99%

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer

et al. 2020

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Background: As surgery remains the cornerstone of colorectal cancer (CRC) treatment, the number of older patients presented for colorectal resection is rapidly increasing. Nevertheless, the choice to operate an oldest-old patient still remain challenging and requires a careful assessment of risk to benefit ratio in order to guarantee appropriate surgical strategies and perioperative management. Case presentation: A centenarian patient, acutely admitted to the emergency department, was diagnosed with an ileus caused by stenosing ascending colon cancer with abnormal distension of the right colon at high risk of perforation. Facing with this complex clinical scenario, a lateral decompressive cecostomy as alternative surgical procedure, was performed in local anesthesia in order to avoid the stressful event of an emergency surgery. Thereafter, the patient was admitted to the surgical ward and followed by a geriatrician who performed a comprehensive geriatric assessment (CGA) and daily clinical evaluations. This integrated plan of care was mainly focused on rehabilitation, nutritional interventions and therapeutic reconciliation, maximizing patient's clinical conditions and performance status. Then, the second surgical step, the radical colon surgery with curative intent and bowel continuity reestablishment was performed, demonstrating to be feasible and safety also in a very advanced age patient in term of prolonged survival and preservation of an adequate quality of life. Conclusions: This is the first case-report that illustrates a successful two step surgery for CRC in a centenarian patient thanks to a multidisciplinary based approach, overwhelming the mere concept of chronological age.

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Establishing a proactive geriatrician led comprehensive geriatric assessment in older emergency surgery patients: Outcomes of a pilot study

Abstract: Proactive geriatrician input identifies medical diagnoses and geriatric syndromes missed by the surgical teams. Managing these issues has contributed to a reduced length of stay in these patients.

Cited by 14 publications

References 25 publications

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

A review of ASA physical status – historical perspectives and modern developments

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer

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