Association of the Hospital Volume of Frail Surgical Patients Cared for with Outcomes after Elective, Major Noncardiac Surgery

Abstract Background Frailty is a risk factor for adverse postoperative outcomes. Hospitals that perform higher volumes of surgery have better outcomes than low-volume providers. We hypothesized that frail patients undergoing elective surgery at hospitals that cared for a higher volume of similarly frail patients would have improved outcomes. Methods We conducted a retrospective, population-based cohort study using linked administrative data in Ontario, Canada. We identified all adult major, elective noncardiac surgery patients who were frail according to the validated Johns Hopkins Adjusted Clinical Groups (ACG®) frailty-defining diagnoses indicator. Hospitals were categorized into frailty volume quintiles based on volumes of frail surgical patients cared for. Multilevel, multivariable modeling measured the association of frailty volume with 30-day survival (primary outcome), complications, failure to rescue (secondary outcomes), and costs (tertiary outcome). Results Of 63,381 frail patients, 708 (1.1%) died after surgery. The thirty-day mortality rate in the lowest volume quintile was 1.1% compared to 0.9% in the highest. After adjustment for surgical risk, demographic characteristics, comorbidities, and clustering within hospitals, we found a significant association between frailty volume and improved survival (highest volume vs. lowest volume quintile: hazard ratio 0.51; 95% CI, 0.35 to 0.74; P < 0.0001). Although complication rates did not vary significantly between hospitals, failure-to-rescue rates were inversely related to volume. Conclusions Frail patients have reduced survival and increased failure to rescue when they undergo operations at hospitals having a lower volume of frail surgical patients. Concentration of perioperative care in centers that frequently treat high-risk frail patients could improve population outcomes.

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Frailty in the over 65’s undergoing elective surgery (FIT-65) – a three-day study examining the prevalence of frailty in patients presenting for elective surgery

10.21203/rs.3.rs-982059/v1 ◽

2021 ◽

Author(s):

Sarah Harrison ◽

David Alexander Harvie ◽

Lewis Matthews ◽

Frances Wensley

Keyword(s):

Length Of Stay ◽

Elective Surgery ◽

Smoking Status ◽

Perioperative Complications ◽

Surgical Patients ◽

Early Screening ◽

Cross Sectional ◽

Operative Data ◽

Frail Patients ◽

The Uk

Abstract Background Frailty increases the risk of perioperative complications, length of stay, and the need for assisted-living after discharge. As the UK population ages the number of frail patients presenting for elective surgery in the UK is likely to grow. Despite the potential benefits of early diagnosis, frailty is not uniformly screened for in UK elective surgical patients and its prevalence remains unclear. The primary aim of this study was to assess the prevalence of frailty in patients aged over 65 years undergoing elective surgery. Methods We performed a prospective cross-sectional observational study in eight UK hospitals. Data were collected over three consecutive days with follow-up at 30 days. HRA approval was obtained (REC 20/SC/0121) and signed informed consent obtained. Participants were eligible for inclusion if they were 65 years or older and undergoing elective surgery. Pre-operative data were collected from hospital notes by anaesthetic trainees. A member of the research team blinded to the pre-operative dataset screened the participant for frailty pre-operatively using the Reported Edmonton Frail Scale (REFS). Post-operative data were collected from the notes on day of surgery and at 30 days. Participants were defined as “frail” if they scored 8 or more on the REFS. Results 228 participants were recruited during the study period of whom 218 proceeded to surgery. There were 103 females and 115 males. Median age was 75 years (interquartile range 70-80). Thirty-seven participants (17.0%) were identified as frail. Frail patients were older, had a higher ASA score, were more likely to have carers and were more likely to be anaemic and present with ECG abnormalities. There were no differences in gender, BMI, place of residence or smoking status for patients identified as frail versus non-frail. There was no difference in length-of-stay between frail and non-frail patients, although those identified as frail were less likely to be discharged to their own home. Conclusion We found the prevalence of frailty in a mixed population of elective surgical patients aged 65 or over to be 17.0%. Furthermore, we found the REFS to be a practical tool for pre-operative frailty screening. Frail patients presented for elective surgery with modifiable co-morbidities which could have been optimised pre-operatively. Early screening could highlight frail patients, allowing time for pre-operative planning and evidence-based optimisations of comorbidities. We therefore encourage the adoption of frailty assessment as a routine part of pre-operative assessment.

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Acute Stroke

10.1093/med/9780190226459.003.0063 ◽

2017 ◽

Author(s):

Laurel E. Moore

Keyword(s):

Neurological Disorders ◽

Postoperative Morbidity ◽

Elective Surgery ◽

The United States ◽

Noncardiac Surgery ◽

Perioperative Stroke ◽

Systemic Thrombolysis ◽

Central Focus ◽

Improved Outcomes ◽

History Of

Stroke is the leading cause of disability in the United States, and in terms of mortality is second only to ischemic heart disease worldwide. Medical management for acute ischemic stroke (AIS) was limited to supportive care until 1995, when the National Institute of Neurological Disorders and Stroke (NINDS) trial demonstrated improved outcomes with systemic thrombolysis for AIS. Since December 2014, four major articles have been published in support of endovascular intervention for AIS, making this a central focus of this chapter. Other related topics for this chapter include the timing of elective surgery following stroke, how to assess perioperative risk for patients having a history of remote stroke, and implications for postoperative morbidity and mortality associated with perioperative stroke in noncardiac surgery.

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Faculty Opinions recommendation of Association of the Hospital Volume of Frail Surgical Patients Cared for with Outcomes after Elective, Major Noncardiac Surgery: A Retrospective Population-based Cohort Study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727274145.793536127 ◽

2017 ◽

Author(s):

Yoshinori Nakata

Keyword(s):

Cohort Study ◽

Hospital Volume ◽

Population Based ◽

Noncardiac Surgery ◽

Surgical Patients

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The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

BMC Health Services Research ◽

10.1186/s12913-021-06140-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dimuthu Rathnayake ◽

Mike Clarke

Keyword(s):

Primary Care ◽

Health Systems ◽

Elective Surgery ◽

Waiting Times ◽

Surgical Care ◽

High Income ◽

Surgical Patients ◽

Timely Access ◽

Referral Systems

Abstract Background Long waiting times for elective surgery are common to many publicly funded health systems. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. Primary care practitioners play a major role in determining which patients are referred to surgeon and might represent an opportunity to improve this situation. With conventional methods of referrals, surgery clinics are often overcrowded with non-surgical referrals and surgical patients experience longer waiting times as a consequence. Improving the quality of referral communications should lead to more timely access and better cost-effectiveness for elective surgical care. This review summarises the research evidence for effective interventions within the scope of primary-care referral methods in the surgical care pathway that might shorten waiting time for elective surgeries. Methods We searched PubMed, EMBASE, SCOPUS, Web of Science and Cochrane Library databases in December-2019 to January-2020, for articles published after 2013. Eligibility criteria included major elective surgery lists of adult patients, excluding cancer related surgeries. Both randomised and non-randomised controlled studies were eligible. The quality of evidence was assessed using ROBINS-I, AMSTAR 2 and CASP, as appropriate to the study method used. The review presentation was limited to a narrative synthesis because of heterogeneity. The PROSPERO registration number is CRD42019158455. Results The electronic search yielded 7543 records. Finally, nine articles were considered as eligible after deduplication and full article screening. The eligible research varied widely in design, scope, reported outcomes and overall quality, with one randomised trial, two quasi-experimental studies, two longitudinal follow up studies, three systematic reviews and one observational study. All the six original articles were based on referral methods in high-income countries. The included research showed that patient triage and prioritisation at the referral stage improved timely access and increased the number of consultations of surgical patients in clinics. Conclusions The available studies included a variety of interventions and were of medium to high quality researches. Managing patient referrals with proper triaging and prioritisation using structured referral formats is likely to be effective in health systems to shorten the waiting times for elective surgeries, specifically in high-income countries.

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Survival and Complication Rates of Metastasectomy in Patients With Metastatic Renal Cell Carcinoma Treated Exclusively With Targeted Therapy: A Combined Population-based Analysis

Anticancer Research ◽

10.21873/anticanres.13604 ◽

2019 ◽

Vol 39 (8) ◽

pp. 4357-4361 ◽

Cited By ~ 4

Author(s):

CARLOTTA PALUMBO ◽

ANGELA PECORARO ◽

SOPHIE KNIPPER ◽

GIUSEPPE ROSIELLO ◽

ZHE TIAN ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Targeted Therapy ◽

Cell Carcinoma ◽

Metastatic Renal Cell Carcinoma ◽

Renal Cell ◽

Population Based ◽

Complication Rates

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Admission and Acute Complication Rate for Outpatient Lumbar Microdiscectomy

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100009641 ◽

2010 ◽

Vol 37 (1) ◽

pp. 49-53 ◽

Cited By ~ 19

Author(s):

Aria Fallah ◽

Eric M. Massicotte ◽

Michael G. Fehlings ◽

Stephen J. Lewis ◽

Yoga Raja Rampersaud ◽

...

Keyword(s):

Complication Rate ◽

Admission Rate ◽

Complication Rates ◽

Chi Square ◽

Lumbar Microdiscectomy ◽

Acute Complication ◽

Admission Data ◽

Improved Outcomes ◽

Significant Difference ◽

Revision Operations

Objective:Specialization is generally independently associated with improved outcomes for most types of surgery. This is the first study comparing the immediate success of outpatient lumbar microdiscectomy with respect to acute complication and conversion to inpatient rate. Long term pain relief is not examined in this study.Methods:Two separate prospective databases (one belonging to a neurosurgeon and brain tumor specialist, not specializing in spine (NS) and one belonging to four spine surgeons (SS)) were retrospectively reviewed. All acute complications as well as admission data of patients scheduled for outpatient lumbar microdiscectomy were extracted.Results:In total, 269 patients were in the NS group and 137 patients were in the SS group. The NS group averaged 24 cases per year while the SS group averaged 50 cases per year. Chi-square tests revealed no difference in acute complication rate [NS(6.7%), SS(7.3%)] (p>0.5) and admission rate [NS(4.1%), SS(5.8%)] (p=0.4) while the SS group had a significantly higher proportion of patients undergoing repeat microdiscectomy [NS(4.1%), SS(37.2%)] (p<0.0001). Excluding revision operations, there was no statistically significant difference in acute complication [NS(5.4%), SS(1.2%)] (p=0.09) and conversion to inpatient [NS(4.3%), SS(4.6%)] (p>0.5) rate. The combined acute complication and conversion to inpatient rate was 6.9% and 4.7% respectively.Conclusion:Based on this limited study, outpatient lumbar microdiscectomy can be apparently performed safely with similar immediate complication rates by both non-spine specialized neurosurgeons and spine surgeons, even though the trend favored the latter group for both outcome measures.

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Absence of Association between Preoperative Estimated Glomerular Filtration Rates and Postoperative Outcomes following Elective Gastrointestinal Surgeries: A Prospective Cohort Study

Anesthesiology Research and Practice ◽

10.1155/2018/5710641 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7

Author(s):

Sivesh K. Kamarajah ◽

Behrad Barmayehvar ◽

Mustafa Sowida ◽

Amirul Adlan ◽

Christina Reihill ◽

...

Keyword(s):

Risk Stratification ◽

Glomerular Filtration ◽

Elective Surgery ◽

Gastrointestinal Surgery ◽

Major Complication ◽

Postoperative Outcomes ◽

Queen Elizabeth Hospital ◽

Complication Rates ◽

Significant Difference ◽

The Impact

Background. Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods. This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results. This study included 370 patients, of which 11% (41/370) had eGFR of <60 ml/min/1.73 m2. Patients with eGFR < 60 ml/min/1.73 m2 were more likely to have ASA grade 3/4 (p<0.001) and >2 comorbidities (p<0.001). Overall complication rates were 15% (54/370), with no significant difference in overall (p=0.644) and major complication rates (p=0.831) between both groups. In adjusted models, only surgery grade was predictive of overall complications. Preoperative eGFR did not impact on overall complications (HR: 0.89, 95% CI: 0.45–1.54; p=0.2). Conclusions. Preoperative eGFR does not appear to impact on postoperative complications in patients undergoing elective gastrointestinal surgeries, even when stratified by surgery grade. These findings will help preassessment clinics in risk stratification and optimisation of perioperative care of patients.

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Age-related inequalities in colon cancer treatment persist over time: a population-based analysis

Journal of Epidemiology & Community Health ◽

10.1136/jech-2018-210842 ◽

2018 ◽

Vol 73 (1) ◽

pp. 34-41 ◽

Cited By ~ 3

Author(s):

Louise Hayes ◽

Lynne Forrest ◽

Jean Adams ◽

Mira Hidajat ◽

Yoav Ben-Shlomo ◽

...

Keyword(s):

Colon Cancer ◽

Cancer Treatment ◽

Treatment Decision ◽

Population Based ◽

Surgical Patients ◽

Area Deprivation ◽

Treatment Decision Making ◽

Colon Cancers ◽

Age Related ◽

Over Time

BackgroundOlder people experience poorer outcomes from colon cancer. We examined if treatment for colon cancer was related to age and if inequalities changed over time.MethodsData from the UK population-based Northern and Yorkshire Cancer Registry on 31 910 incident colon cancers (ICD10 C18) diagnosed between 1999–2010 were obtained. Likelihood of receipt of: (1) cancer-directed surgery, (2) chemotherapy in surgical patients, (3) chemotherapy in non-surgical patients by age, adjusting for sex, area deprivation, cancer stage, comorbidity and period of diagnosis, was examined.ResultsAge-related inequalities in treatment exist after adjustment for confounding factors. Patients aged 60– 69, 70–79 and 80+ years were significantly less likely to receive surgery than those aged <60 years (multivariable ORs (95% CI) 0.84(0.74 to 0.95), 0.54(0.48 to 0.61) and 0.19(0.17 to 0.21), respectively). Age-related differences in receipt of surgery and adjuvant chemotherapy (but not chemotherapy in non-surgical patients) narrowed over time for the ’younger old’ (aged <80 years) but did not diminish for the oldest patients.ConclusionsAge inequality in treatment of colon cancer remains after adjustment for confounders, suggesting age remains a major factor in treatment decisions. Research is needed to better understand the cancer treatment decision-making process, and how to influence this, for older patients.

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