Perioperative Geriatric Care Effective but Rare

Older patients presenting for major elective surgeries do not often receive perioperative geriatric care, a Canadian study has concluded. These findings fly in the face of current research, which has demonstrated that preoperative geriatric evaluations improve postoperative outcomes in this age group, a finding corroborated by the current study. The conclusions probably also can be extrapolated to patients in the United States.

“As we all know, our overall population is getting much older,” said Daniel I. McIsaac, MD, MPH, an assistant professor of anesthesiology and pain medicine at the University of Ottawa, in Ontario, and an adjunct scientist at the Institute for Clinical Evaluative Sciences, in Toronto. “People older than 65 years of age are by far the fastest-growing demographic of people who are having elective surgery, and advanced age independently predicts a significant increase in rates of postoperative adverse events.

“We’ve been working to figure out what we can do to improve the care of our older surgical patients, and preoperative geriatric evaluations have yielded promising results in previous research,” he said, citing a study in Anaesthesia (2014;69[suppl 1]:8-16). “Nevertheless, we really don’t have any population-based data to understand if preoperative geriatric evaluations are even occurring in our patients, or how effective they are.”

Elective Noncardiac Surgery

Given this knowledge gap, the researchers sought to describe the frequency of preoperative geriatric evaluations, and to estimate the independent association between these assessments and postoperative outcomes. From an Ontario patient database, they identified 266,499 patients who were at least 65 years of age on the day of their first elective noncardiac surgery between 2002 and 2014. Geriatric consultations and comprehensive assessments were identified using validated physician billing codes. The investigators used multilevel, multivariable-adjusted regression analyses to estimate the association between geriatric evaluations and 90-day mortality, complications, hospital length of stay and discharge independence.

As Dr. McIsaac reported at the 2017 annual meeting of the Canadian Anesthesiologists’ Society (abstract 281666), preoperative geriatric evaluations were performed only in 2.8% of patients (n=7,352). “Interestingly, despite accumulating evidence and focus on geriatric care, we saw no difference from 2002 to 2014 in terms of the number of people who were seeing a geriatrician before surgery,” he said. “In fact, most of the patients who saw a geriatrician were having major joint arthroplasty, which really is the lowest-risk surgery in our cohort.”

Death within 90 days of surgery occurred in 14 per 1,000 patients who were evaluated by a geriatrician, compared with 24 per 1,000 of those who were not. After statistical adjustment, preoperative geriatric evaluation was still found to be significantly associated with improved survival (hazard ratio, 0.81; 95% CI, 0.68-0.95). Despite these differences in mortality, rates of complications did not differ between groups.

“People who were seen by a geriatrician before surgery were more likely to go home with supportive care, rehabilitation or to long-term care institutions,” Dr. McIsaac said. “Accordingly, there was a slight increase in their overall adjusted cost of care after surgery.”

These results, according to the researchers, may indicate that seeing a geriatrician preoperatively provides a mechanism to more effectively match patient needs to their postoperative care. “A 3% increase in costs after one of these surgeries ends up being about $1,000, which would certainly fall within a reasonable cost-effectiveness ratio,” Dr. McIsaac said. “Nevertheless, we really need more data moving forward to figure out which patients are most likely to benefit from a preoperative geriatric consultation, as well as strategies to engage our geriatric colleagues and perioperative colleagues for putting pathways in place to appropriately involve multidisciplinary geriatrics care.

“So, despite accumulating evidence that it’s likely good for some patients to see a geriatrician before surgery, there’s no evidence that we’re actually doing that,” he concluded.

Session moderator Stephen Kowalski, MD, questioned whether expanding the reach of after-care programs may serve to ultimately improve outcomes in older patients. “You alluded to supported discharge programs,” said Dr. Kowalski, a professor of anesthesiology at the University of Manitoba, in Winnipeg. “Do you think these types of programs should be available to more patients? Should we be looking at more ways of expanding the availability of these programs?”

“I think we can do a better job of identifying patients who are going to need supported care after surgery,” Dr. McIsaac replied. “Do you need to see a geriatrician to have that done? Probably not. But we probably need to build that into the perioperative system of care, where it’s set up before patients come to the hospital.”