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Hospitals with more ‘frail’ surgery patients have better outcomes
March 24, 2017 / 4:35 PM / 8 months ago

Hospitals with more ‘frail’ surgery patients have better outcomes

(Reuters Health) - Hospitals with the highest volumes of “frail” surgery patients tend to be where such patients fare better, a recent study in Canada suggests.

Frail patients have multiple medical issues, often including a history of falls, difficulty with walking, impaired vision and dementia as they age, the study authors write in the journal Anesthesiology - and surgical teams need to pay greater attention to these patients.

“Our population is aging rapidly, and older patients have surgery at a higher rate than any other age group,” said lead study author Daniel McIsaac of the University of Ottawa.

“We know that being frail before surgery is a risk factor for death, complications and nursing home discharge across most surgery types,” he told Reuters Health. “If frailty is a strong risk factor, what can we do to decrease this risk?”

Previous research has found that hospitals with a higher volume of complicated surgical procedures have better outcomes, he added, and hospitals with a higher volume of complicated patients have better outcomes as well.

To see if hospitals with higher volumes of frail surgical patients also do better, McIsaac and colleagues studied data on more than 63,300 frail patients in Ontario who had non-cardiac surgeries. They found that 708, or 1.1 percent, died within 30 days of the procedure.

Hospitals in the top-fifth for frail-patient volume had mortality rates of 0.9 percent within 30 days. But when researchers accounted for patient characteristics and health conditions and the riskiness of the surgery, they found the likelihood of death was cut by about half in the hospitals with the highest volume of frail patients compared to those with the lowest volume.

Complications didn’t vary much between hospitals, but so-called “failure to rescue” events during surgery dropped as hospital volume of frail patients went up.

“Specialization in the care of frail patients is a strategy to consider,” McIsaac said. “In these high-volume hospitals, there may already be processes in place to help our frail older patients.”

“If we can’t identify the older individuals who are frail, we can’t start to apply best practices to help improve their outcomes,” McIsaac said. “We also need to evaluate these high-volume hospitals to see how and why their frail patients do better.”

That may include better monitoring of frail patients for potential complications, or multidisciplinary care by a team of coordinated surgeons, anesthesiologists, gerontologists and nurse specialists.

“Over the last five years, there’s increasing recognition that we need to develop health systems that are sensitive to aging patients’ unique needs,” said Mark Neuman of the University of Pennsylvania in Philadelphia who wasn’t involved with the study.

“Frailty has been discussed in aging for a long time, but now it’s filtering into our consciousness for surgery and anesthesia,” he told Reuters Health. “It has real implications for longevity and quality of life, and we need to be sensitive and aware.”

The American College of Surgeons created the Coalition for Quality in Geriatric Surgery to improve surgical care for older adults by creating standards that address the unique physiological, social and surgical needs of older adults. Set to launch in 2019, the geriatric surgery program will focus on the full cycle of care, including pre-surgery and post-surgery guidelines.

“Not too far down the road, we may choose hospitals that are better at caring for frail adults in the same way people choose hospitals with good reputations for heart surgery or knee surgery,” Neuman said.

New developments within health systems, such as the perioperative surgical home, may help frail patients before, during and after surgery as well, he said.

“Surgery happens in the context of a life story,” Neuman noted. “With older adults, we want to understand that context and provide care throughout the process.”

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