Age and Ageing Advance Access originally published online on January 27, 2007
Age and Ageing 2007 36(2):190-196; doi:10.1093/ageing/afl163
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Proactive care of older people undergoing surgery (‘POPS’): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients
Department of Ageing and Health, St. Thomas' Hospital, 9th Floor, North Wing, Lambeth Palace Road, London SE1 7EH, UK
Address correspondence to: Danielle Harari. Tel: 020 7188 2086. Fax: 020 7928 2339. Email: danielle.harari{at}kcl.ac.uk
Background: older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation.
Objective: to design, embed, and evaluate an evidence-based comprehensive geriatric assessment (CGA) service for at-risk older patients undergoing elective surgery.
Setting: urban teaching hospital.
Subjects: elective surgical patients aged 65+.
Intervention: multidisciplinary preoperative CGA service with post-operative follow-through (proactive care of older people undergoing surgery [‘POPS’]).
Methods: observational cohort study and multilevel surveys (development and modelling phase). Prospective ‘before and after’ comparison (exploratory evaluation).
Results: findings from the development phase showed high levels of preoperative co-morbidity, no multidisciplinary preoperative input, and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients. Comparison of 2 cohorts of elective orthopaedic patients (pre-POPS vs POPS, N = 54) showed the POPS group had fewer post-operative medical complications including pneumonia (20% vs 4% [p = 0.008]) and delirium (19% vs 6% [p = 0.036]), and significant improvements in areas reflecting multidisciplinary practice including pressure sores (19% vs 4% [p = 0.028]), poor pain control (30% vs 2% [p<0.001]), delayed mobilisation (28% vs 9% [p = 0.012]) and inappropriate catheter use (20% vs 7% [p = 0.046]). Length of stay was reduced by 4.5 days. There were fewer delayed discharges relating to medical complications (37% vs 13%) or waits for OT assessment or equipment (20% vs 4%).
Conclusion: a proactive evidence-based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions. Pre/post comparison in elective orthopaedic patients showed improved (within methodological limitations) post-operative outcomes indicative of better clinical effectiveness and efficiency, and contributed to the service obtaining mainstream funding. Informed by the present study, a randomised controlled trial is ongoing.
Keywords: older, elective surgery, preoperative, comprehensive geriatric assessment, elderly
Received 20 June 2006; accepted in revised form 31 October 2006.