Projections from the United States census anticipate that one quarter of Americans will be 65 years or older within a decade, effectively doubling to 95 million older adults (asamonitor.pub/3pLIbun). The Administration on Aging finds over 17% of people living in the U.S. are 65 years or older (asamonitor.pub/3rpYxJW). Concentration of older adults within rural communities is greater, with the percentage of total rural population composition accelerating quickly (asamonitor.pub/3NGRzrn). Such unbalanced demographics are reflected among our patients and the rural surgical workforce (N Engl J Med 2019;381:299–301).
These trends are paralleled by rising representation of older patients subject to surgical procedures. Older adults already account for more than half of surgical procedures in the U.S. (Geriatr Orthop Surg Rehabil 2011;2:56-64). Urgent needs exist to develop health delivery systems to support rural perioperative care while maximizing health value and outcomes. Perioperative care is a continuum that spans from surgical contemplation through the preoperative, intraoperative, and postoperative periods and return to function (asahq.org/psh). Our health systems can improve perioperative care of older adults in many areas. Aging patients have unique physiologic, pharmacologic, and psychosocial needs that require careful planning of anesthesia and surgery. Increasing comorbidities, a higher prevalence of frailty, pre-existing cognitive dysfunction (both compensated and not), poor nutrition, and barriers to accessing high-quality care are common. This subpopulation is at increased risk of postoperative morbidity and mortality compared with younger surgical patients (J Am Coll Surg 2006;203:865-77).
Poor access to care is multifactorial and is the first major hurdle. Appreciating the challenges to access is critical to improvements. Appointment availability, geographic distance, and transportation limitations all contribute to older rural patients’ inability to access care. Lack of social support, the inability to drive, anxiety about navigating and leaving home, and not understanding the benefit of an additional appointment are all common barriers facing surgical readiness. Bringing in higher-level services to rural areas, staffed with providers who understand the community, is another barrier to cost-effective rural health care. Perioperative optimization clinics, for example, are cost centers commonly associated with academic hospitals, and efforts to extend their reach to rural communities are necessary.
Hearing and vision loss can often complicate communication. Cognitive dysfunction also has important implications. Barriers to effective communication pose unique challenges for perioperative health experts. Ascertaining health status, as well as ensuring the patient understands the procedure, the expected outcome, and the reality of the postoperative course, including care needs and long-term outcomes, is undermined by ineffective communication.
So how does one provide equitable, high-quality care to an aging, rural surgical population increasingly needing more complex services? Communication between local invested providers who value interdisciplinary work is vital. Creating a system that supports this communication can be inexpensive and effective, but it takes time and energy. Older patients may have many care providers, often in different networks, which results in fragmented and duplicated care. This is further complicated by the broad gamut of medical record platforms and, in many areas, the distances involved. Creating a system that “de-silos” necessary information reduces redundancy, simplifies the patient experience, and promotes value-based care.
Virtual perioperative visits are expanding rapidly and evolving into an effective care platform. Utilizing community support to make telemedicine visits more feasible, such as with volunteers to facilitate use of the technology, could unite rural communities while providing efficient, modern perioperative care. The COVID-19 pandemic likely paved the way for aging patients to embrace modern technology (asamonitor.pub/44GWfEx). Adopting the concept of an interdisciplinary team and agreed-upon criteria, and triaging patients who would benefit from telemedicine versus in-person assessment ensures individualized, value-added care.
Finally, it is vital to address health literacy barriers to ensure adequate assessment, education, and expectations. Having pre-appointment messaging in the patient’s desired method (phone call, email, letter, or proxy) and encouraging patients to wear their hearing aids (and bring extra batteries), bring their glasses, and bring a trusted support person are all critical to streamlining visits and ensuring that our care plans mirror the patient’s expectations.
National initiatives such as Age-Friendly Health Systems and Geriatric Surgical Verification are integral to generating a sustainable and resourced team (Age-friendly health systems: A guide to using the 4Ms while caring for older adults. 2022; asamonitor.pub/3D3Xu4K). Similarly, implementing rural-based anesthesiology education promotes recruitment and retention of the next generation of rural consultant anesthesiologists. Many challenges remain in continuing to provide high-quality and equitable perioperative care for rural older adults, but innovative models ready for implementation can expand if we advocate for them – for the benefit of patients and their surgeons.