Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative

Abstract

Importance: Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients.

Objective: To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization.

Design, setting, and participants: Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH.

Main outcomes and measures: Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets.

Results: One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes.

Conclusions and relevance: Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Figure 1.. Identification of Perioperative Optimization of Senior Health (POSH) Patient Subgroups

^aGeneral surgery cases include cholecystectomies, paraesophageal hernia, ventral hernia, and inguinal hernia repairs.

Figure 2.. Median Length of Stay (LOS) and Readmission Rates by Surgical Approach

A, Comparison of median LOS in days for hospitalization for the primary surgery. B, Comparison of median LOS in days for Perioperative Optimization of Senior Health (POSH) patients vs control patients for laparoscopic vs open procedures. C, Comparison of all-cause readmission rates in percentage at 7 days and 30 days after discharge from hospitalization for surgery. D, Comparison of hospital readmission rates in percentage at 30 days for patients with laparoscopic vs open procedures.

Figure 3.. Discharge Disposition

Comparison of Perioperative Optimization of Senior Health (POSH) patients and control group patients for location and level of care at discharge from hospitalization for primary surgery. The percentage of all patients discharged to either home with self-care (ie, without home health care or other skilled services) vs a need for ongoing health care services (eg, home health care, skilled nursing or acute inpatient rehabilitation, or hospice). Numbers in hospice included 1 for POSH and 0 for control. P value reflects the χ² test of home self-care vs all other dispositions.