Surgical care for the aged: a retrospective cross-sectional study of a national surgical mortality audit

Abstract

Objectives: It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia.

Design: This retrospective cross-sectional study extracted data from a national surgical mortality audit--an independent, peer-reviewed process.

Setting: From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon.

Participants: Notified deaths totalled 19,723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11,376). From this baseline population, we divided 11,201 deaths into three patient age groups: youngest (17-64 years), medium (65-79 years) and oldest (≥80 years).

Outcome measures: Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables.

Results: The baseline population's median age was 78 years (IQR 66-85), 43.7% (4892/11,201) were 80 years or older and 83.4% (9319/11,173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590)).

Conclusions: The oldest patients received lower levels of care than the medium and youngest age groups.

Keywords: aged; clinical audit; mortality; postoperative care; surgery.

Figure 1

Flow chart of included mortality data. †Cases from non-participating surgeons. ‡Cases not returned after 2 years from notification, despite regular reminders, were considered “lots to follow-up”. §Cases not returned, but <2 years, therefore not “lost of follow-up”. ||Patients classed as American Society of Anaesthesiologists (ASA) 6 are brain-dead.

Figure 2

Trends of postoperative factors versus age (2009–2012).