Association of integrated care coordination with postsurgical outcomes in high-risk older adults the Perioperative Optimization of Senior Health (POSH) initiative

Shelley R. McDonald, Mitchell T. Heflin, Heather E. Whitson, Thomas O Dalton, Michael E. Lidsky, Phillip Liu, Cornelia M. Poer, Richard Sloane, Julie K. Thacker, Heidi K. White, Mamata Yanamadala, Sandhya A. Lagoo-Deenadayalan

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

IMPORTANCE Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. OBJECTIVE To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. DESIGN, SETTING, AND PARTICIPANTS Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. MAIN OUTCOMES AND MEASURES Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. RESULTS One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95%CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95%CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95%CI,-1.06 to-4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95%CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95%CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95%CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95%CI,-0.13 to-0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P< .001; 95%CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95%CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. CONCLUSIONS AND RELEVANCE Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Original languageEnglish (US)
Pages (from-to)454-462
Number of pages9
JournalJAMA Surgery
Volume153
Issue number5
DOIs
StatePublished - May 1 2018
Externally publishedYes

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Health
Delirium
Geriatrics
Control Groups
Length of Stay
Perioperative Care
Polypharmacy
Electronic Health Records
Self Care
Quality Improvement
Comorbidity
Weight Loss
Hospitalization
Anesthesia
Outcome Assessment (Health Care)
Databases
Morbidity

ASJC Scopus subject areas

  • Surgery

Cite this

Association of integrated care coordination with postsurgical outcomes in high-risk older adults the Perioperative Optimization of Senior Health (POSH) initiative. / McDonald, Shelley R.; Heflin, Mitchell T.; Whitson, Heather E.; Dalton, Thomas O; Lidsky, Michael E.; Liu, Phillip; Poer, Cornelia M.; Sloane, Richard; Thacker, Julie K.; White, Heidi K.; Yanamadala, Mamata; Lagoo-Deenadayalan, Sandhya A.

In: JAMA Surgery, Vol. 153, No. 5, 01.05.2018, p. 454-462.

Research output: Contribution to journalArticle

McDonald, SR, Heflin, MT, Whitson, HE, Dalton, TO, Lidsky, ME, Liu, P, Poer, CM, Sloane, R, Thacker, JK, White, HK, Yanamadala, M & Lagoo-Deenadayalan, SA 2018, 'Association of integrated care coordination with postsurgical outcomes in high-risk older adults the Perioperative Optimization of Senior Health (POSH) initiative', JAMA Surgery, vol. 153, no. 5, pp. 454-462. https://doi.org/10.1001/jamasurg.2017.5513
McDonald, Shelley R. ; Heflin, Mitchell T. ; Whitson, Heather E. ; Dalton, Thomas O ; Lidsky, Michael E. ; Liu, Phillip ; Poer, Cornelia M. ; Sloane, Richard ; Thacker, Julie K. ; White, Heidi K. ; Yanamadala, Mamata ; Lagoo-Deenadayalan, Sandhya A. / Association of integrated care coordination with postsurgical outcomes in high-risk older adults the Perioperative Optimization of Senior Health (POSH) initiative. In: JAMA Surgery. 2018 ; Vol. 153, No. 5. pp. 454-462.
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abstract = "IMPORTANCE Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. OBJECTIVE To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. DESIGN, SETTING, AND PARTICIPANTS Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. MAIN OUTCOMES AND MEASURES Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. RESULTS One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95{\%}CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95{\%}CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95{\%}CI,-1.06 to-4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8{\%}] vs 14 of 142 [9.9{\%}]; P = .007; 95{\%}CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8{\%}] vs 26 of 142 [18.3{\%}]; P = .004; 95{\%}CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3{\%}] vs 73 of 143 [51.1{\%}]; P = .04; 95{\%}CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95{\%}CI,-0.13 to-0.89) despite higher rates of documented delirium (52 of 183 [28.4{\%}] vs 8 of 143 [5.6{\%}]; P< .001; 95{\%}CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50{\%}] vs 55 of 143 [38.5{\%}]; P = .001; 95{\%}CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. CONCLUSIONS AND RELEVANCE Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.",
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T1 - Association of integrated care coordination with postsurgical outcomes in high-risk older adults the Perioperative Optimization of Senior Health (POSH) initiative

AU - McDonald, Shelley R.

AU - Heflin, Mitchell T.

AU - Whitson, Heather E.

AU - Dalton, Thomas O

AU - Lidsky, Michael E.

AU - Liu, Phillip

AU - Poer, Cornelia M.

AU - Sloane, Richard

AU - Thacker, Julie K.

AU - White, Heidi K.

AU - Yanamadala, Mamata

AU - Lagoo-Deenadayalan, Sandhya A.

PY - 2018/5/1

Y1 - 2018/5/1

N2 - IMPORTANCE Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. OBJECTIVE To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. DESIGN, SETTING, AND PARTICIPANTS Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. MAIN OUTCOMES AND MEASURES Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. RESULTS One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95%CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95%CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95%CI,-1.06 to-4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95%CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95%CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95%CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95%CI,-0.13 to-0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P< .001; 95%CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95%CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. CONCLUSIONS AND RELEVANCE Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

AB - IMPORTANCE Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. OBJECTIVE To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. DESIGN, SETTING, AND PARTICIPANTS Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. MAIN OUTCOMES AND MEASURES Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. RESULTS One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95%CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95%CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95%CI,-1.06 to-4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95%CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95%CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95%CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95%CI,-0.13 to-0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P< .001; 95%CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95%CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. CONCLUSIONS AND RELEVANCE Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

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