Proactive care of older people undergoing surgery (‘POPS’): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients

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Abstract

Background

older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation.

Objective

to design, embed, and evaluate an evidence-based comprehensive geriatric assessment (CGA) service for at-risk older patients undergoing elective surgery.

Setting

urban teaching hospital.

Subjects

elective surgical patients aged 65+.

Intervention

multidisciplinary preoperative CGA service with post-operative follow-through (proactive care of older people undergoing surgery [‘POPS’]).

Methods

observational cohort study and multilevel surveys (development and modelling phase). Prospective ‘before and after’ comparison (exploratory evaluation).

Results

findings from the development phase showed high levels of preoperative co-morbidity, no multidisciplinary preoperative input, and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients. Comparison of 2 cohorts of elective orthopaedic patients (pre-POPS vs POPS, N=54) showed the POPS group had fewer post-operative medical complications including pneumonia (20% vs 4% [p=0.008]) and delirium (19% vs 6% [p=0.036]), and significant improvements in areas reflecting multidisciplinary practice including pressure sores (19% vs 4% [p=0.028]), poor pain control (30% vs 2% [p<0.001]), delayed mobilisation (28% vs 9% [p=0.012]) and inappropriate catheter use (20% vs 7% [p=0.046]). Length of stay was reduced by 4.5 days. There were fewer delayed discharges relating to medical complications (37% vs 13%) or waits for OT assessment or equipment (20% vs 4%).

Conclusion

a proactive evidence-based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions. Pre/post comparison in elective orthopaedic patients showed improved (within methodological limitations) post-operative outcomes indicative of better clinical effectiveness and efficiency, and contributed to the service obtaining mainstream funding. Informed by the present study, a randomised controlled trial is ongoing.

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