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May08

Posted by:John Ellis
Comments: (1)

Ofttime, studies in the literature exclude patients with comorbidites, making the generalizability of trials difficult.  The two most commonly used risk assessment systems have been the Lee Revised Cardiac Risk Index (RCRI) and the ASA classification. However, things may be more complicated in the “old-old.”

A few years ago, a group from Hopkins showed that frailty scores had additive predictive value for outcomes after surgery, over and above the Lee RCRI.  This is not surprising, since Lee predicts CARDIAC events, yet we know that pulmonary, renal, gut, and brain failure are huge problems in the elderly.

A new prospective study from Seoul confirms these findings:

Nearly 300 patients aged 65 and older who were undergoing elective surgery at a single hospital were scored on nine preoperative characteristics: malignancy, comorbidities, albumin level, activities of daily living, instrumental activities of daily living, dementia, delirium risk, malnutrition, and arm circumference. The highest potential score, indicating highest risk, was 15.

Compared with low-risk patients (score, 5 or lower), high-risk patients (above 5) had a higher 1-year mortality risk (hazard ratio, 9.01) and longer postoperative hospital stays (median, 9 vs. 6 days).

The geriatric assessment proved superior for predicting mortality compared to ASA classification, as shown by greater “area under the curve” (AUC) on the receiver operating characteristic.

What exactly went into this scoring system?

Given the high risks in some of these patients, does it always make sense to proceed with surgery when these new scales predict poor outcomes.  My Penn colleague, Mark Neuman and others, asked this question last month in a Perspectives piece in NEJM:

The process by which surgical decisions are made has remained largely unchanged since William Halsted’s time. Typically, decisions are made after a discussion between a surgeon and the patient and perhaps the patient’s spouse, partner, child, or caregiver. Other physicians — cardiologists, pulmonologists — are sometimes called in to provide clearance to pursue a planned procedure or for assistance after a complication occurs…

Yet this approach may be suboptimal for many high-risk elderly patients facing decisions about major surgery. Patients may not always be presented with all treatment options, including watchful waiting, medical treatment, less invasive surgical options, or percutaneous approaches. Patient-centered care means that patients make health care decisions in partnership with their physicians and that these decisions are driven by the patients’ values and preferences… In the future, multidisciplinary teams could meet regularly to present and discuss high-risk cases….

Evaluating treatment options, formulating recommendations, and articulating the benefits and risks to patients comprehensibly require more than a well-informed or experienced surgeon…

They go on to suggest:

Achieving the best outcomes in the sickest and most frail patients “takes a village…”  Before a high-risk patient entered the surgical home for treatment, an overall management plan would be discussed by a multidisciplinary team, similar to the tumor board review that is now routine in oncology…

If teamwork and care coordination could be built into the DNA of the surgical multidisciplinary team, high-risk patients might be more likely to receive high-quality care and less likely to have complications or require rehospitalization

This Perspectives is about geriatric surgery, but it is also about  ethics, teamwork, leadership.  Your thoughts?




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