Incorporating Patient-centered Outcomes Into Surgical Care
Historically, 30-day morbidity and mortality has been recognized as the gold standard for judging quality of care. This paradigm is under pressure due to the aging demographics of surgical patients. Older adults now account for almost 40% of all inpatient operations in the United States, a percentage that will continue to increase in the next several decades. Because older adults have a limited lifespan, patient-centered outcomes are essential to measure quality of care following an operation. For example, consider the case of an independent living older adult who undergoes a major operation. The inpatient postoperative course is uncomplicated; the patient is discharged to a nursing home and subsequently dies 60 days following the operation without ever returning home. According to our current paradigm of 30-day morbidity and mortality, this scenario represents high quality of care; however, most older adults and their families would judge the quality of this outcome as poor.
The current article by Hshieh et al1 provides high-quality data on the patient-centered outcome of long-term physical function following major operations. The deterioration of physical function associated with patients who developed delirium is a particularly compelling finding given strong evidence that one-third of hospitalized delirium in older adults is preventable by implementing multi-disciplinary environmental supportive measures during the hospital stay.2 Studies like the current one provide surgeons essential data with which to counsel older adults on anticipated functional outcomes after an operation. Furthermore, studies such as this give regulators evidence-based trajectories of postoperative physical function upon which to develop patient-centered quality measures.
The current study complements other work published from this group on the long-term patient-centered outcome of mental, or brain, function following major surgery. In a cohort of patients 60 years and older following cardiac operations, postoperative delirium was associated with clinically important cognitive impairment for up to 1 year, compared with patients who did not develop delirium.3 In patients 70 years and older without dementia, a separate study found clinically meaningful decreases in cognitive function at 1 year.4 Again, because one-third of cases of postoperative delirium are preventable, these studies provide data to suggest that longer term impairments in cognition may be avoided, if delirium can be prevented in the postoperative setting.
While physical and mental long-term function are two important patient-centered outcomes, there are many additional patient-centered outcomes studied in the surgical literature that could be considered for inclusion in surgical quality datasets. Such patient-centered outcomes may include fatigue, pain, sleep disruption, depression, anxiety, decision regret, caregiver burden, and social interactions.
Studies like the current one by Hshieh et al1 emphasize the importance of patient-centered outcomes and challenge the surgical community to use this information to initiate these types of quality of care processes at the local and national level. There is no question that functional data from research like the current study are highly refined and span across a clinically important 18-month timeframe. However, it is critical to ensure that functional outcomes shift from research into clinical quality metrics reviewed by hospital executive and clinical leadership who aim to improve care locally. An excellent example of a national surgical quality program taking on patient-centered outcomes for older adults is the American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) Geriatric Surgery Pilot Program.