It’s Time to Reframe How We Care for Older Adults Facing Surgery

Dr. Ko is Director of the American College of Surgeons Division of Research and Optimal Patient Care and ACS NSQIP, and Principal Investigator of the Coalition for Quality in Geriatrics Surgery (CQGS) Project, based in Chicago, Illinois. He is a practicing surgeon, who serves as professor of surgery and health services at the UCLA Schools of Medicine and Public Health and holds the Robert and Kelly Day Chair in Surgical Outcomes.

Dr. Rosenthal is Chair of the Geriatric Surgery Task Force, Co-Principal Investigator, CQGS Project. She is professor of surgery at Yale University, and chief of surgery at the VA Connecticut Healthcare System. Specializing in geriatric surgery, Dr. Rosenthal is dedicated to helping older patients who have a variety of gastrointestinal and biliary diseases.

geriatricguidelinescover finalThe United States population is dramatically aging. The baby boom generation has reached 65. In fact, there are at least 10,000 people turning 65 every day. The U.S. Census Bureau projects the percentage of men and women 65 years and older will more than double between 2010 and 2050.

Now, more than ever, we see a demographic imperative to pay attention to the rapidly growing number of older adults.  Despite the fact that patients 65 and older make up only 13 percent of the U.S. population, they account for more than one-third of the operations we perform in the U.S. each year.

At the same time, we know there’s much room for improving the outcomes in older patients. Today, people live longer with multiple chronic diseases other than the surgical disease, which means taking care of a frail 75-year-old is much more challenging than taking care of a healthy 50-year-old. But research shows raising the standards of surgical care for older adults improves their outcomes.

It should come as no surprise that the medical and surgical needs of older patients, who typically face complex issues, are not totally being met. Today, health care providers need a new framework to determine whether surgery is appropriate for older adults and, if so, how to provide it in a way that addresses their underlying issues.

That brings us to the question: how can we provide older adults the safe, high-quality, patient-centered surgical care they need and deserve?

In 2015, the American College of Surgeons (ACS), in partnership with the John A. Hartford Foundation, launched a four-year initiative aimed at reframing how we deliver care to this population.  In doing so, we formed the Coalition for Quality in Geriatric Surgery (CQGS), a group of 58 stakeholders representing a wide spectrum of perspectives, including organizations representing patients and families, surgical specialties, anesthesiologists, nursing, social work, regulators, and insurers.

The purpose of the CQGS Project is to bring this diverse group together in order to develop a standards and verification program for U.S. hospitals that will improve care and outcomes for surgical patients 65 and older.  So far, the coalition has done an amazing job of providing input on what universal geriatric surgical care should be.

Before we started this project, the ACS Geriatric Surgery Task Force, in collaboration with the American Geriatrics Society (AGS), produced a set of best practices guidelines (released in 2012) for the preoperative assessment of older patients. Building on those guidelines, we released in January 2016 a second collaborative best practices guidelines for the perioperative management of older patients. These two sets of guidelines, based on decades of research and expert opinion, provided us a springboard for improving geriatric surgical care.

We are one year into this project and are making great strides. These expert guidelines, along with quality indicators, are the basis of a set of preliminary standards we recently created. The final set of standards will serve as the foundation for our geriatric surgery program.

Our team is now focused on developing new outcome measures that will enable us to determine whether or not the program is actually working. We’re also creating a registry to collect common measures like 30-day morbidity and mortality rates, as well as new outcome variables that matter more to older patients, such as functional decline, cognitive recovery, and other patient-reported outcomes.

Another part of this project will be to develop educational materials for patients and their caregivers, as well as valuable programs and tools for providers to enhance their understanding of geriatric care and the surgeon decision making process. We’ll also be building a peer-reviewed verification program, similar to the ACS trauma, cancer, and bariatric quality programs. Through this verification program, the ACS will ensure that the appropriate infrastructure, care processes and resources are in place at participating hospitals. We’re excited about the 2019 launch of the Geriatric Surgery Verification and Quality Improvement Program.

Fortunately, the successful experience ACS has shown with quality programs has raised the level of care and saved lives in specific surgical areas such as cancer, trauma, and bariatric surgery. The ultimate goal of this new verification program is to provide the opportunity to improve care in all hospitals that take care of older adults, which is almost every hospital in the U.S.

Everyone has a story—a father, a grandmother, dear friend, or an aunt who had to undergo an operation of some kind and had some of their needs go unaddressed. Through this quality geriatric surgery program we hope to change that scenario for this large and vulnerable population.

Resources

More more information about the Coalition for Quality in Geriatric Surgery Visit: https://www.facs.org/quality-programs/geriatric-coalition

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