Sanjay Mohanty

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society

Disclosure Information: Disclosures for the members of t Geriatrics Society Postoperative Delirium Panel are listed in Support: Supported by a grant from the John A Hartford Fou to the Geriatrics-for-Specialists Initiative of the American Geri (grant 2009-0079). This article is a supplement to the American Geriatrics Soci Practice Guidelines for Postoperative Delirium in Older Adu at the American College of Surgeons 100 Annual Clinic San Francisco, CA, October 2014.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Comparing national cancer registries: The National Cancer Data Base (NCDB) and the surveillance, epidemiology, and end results (SEER) program

SANJAY MOHANTY, MD AND KARL Y. BILIMORIA, MD, MS* Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University and Northwestern, Memorial Hospital, Chicago, Illinois Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois Department of Surgery, Henry Ford Hospital, Detroit, Michigan

Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures

IMPORTANCE Older adults are at increased risk for adverse events after surgical procedures. Loss of independence (LOI), defined as a decline in function or mobility, increased care needs at home, or discharge to a nonhome destination, is an important patient-centered outcome measure. OBJECTIVE To evaluate LOI among older adult patients after surgical procedures and examine the association of LOI with readmission and death after discharge in this population. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined 9972 patients 65 years and older with known baseline function, mobility, and living situation undergoing inpatient operations from January 2014 to December 2014 at 26 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project. A total of 4895 patients were excluded because they were totally dependent, classified as class 5 by the American Society of Anesthesiologists, undergoing orthopedic or spinal procedures, or died prior to discharge. EXPOSURES Loss of independence at time of discharge. MAIN OUTCOMES AND MEASURES Readmission and death after discharge. RESULTS Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge. CONCLUSIONS AND RELEVANCE Loss of independence, a patient-centered outcome, was associated with postoperative readmissions and death after discharge. Loss of independence can feasibly be collected across multiple hospitals in a national registry. Clinical initiatives to minimize LOI will be important for improving surgical care for older adults.

Risk of Discharge to Postacute Care A Patient-Centered Outcome for the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator

IMPORTANCE Individualized risk prediction tools have an important role as decision aids for use by patients and surgeons before surgery. Patient-centered outcomes should be incorporated into such tools to widen their appeal and improve their usability. OBJECTIVE To develop a patient-centered outcome for the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator, a web-based, individualized risk prediction tool. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using data from the ACS NSQIP, a national clinical data registry. A total of 973 211 patients from July 2010 to June 2012, encompassing 392 hospitals, were used in this analysis. MAIN OUTCOMES AND MEASURES Risk of discharge to a postacute care setting. RESULTS The overall rate of discharge to postacute care was 8.8%. Significant predictors of discharge to postacute care included being 85 years or older (odds ratio [OR] = 9.17; 95% CI, 8.84-9.50), the presence of septic shock (OR = 2.43; 95% CI, 2.20-2.69) or ventilator dependence (OR = 2.81; 95% CI, 2.56-3.09) preoperatively, American Society of Anesthesiologists class of 4 or 5 (OR = 3.59; 95% CI, 3.46-3.71), and totally dependent functional status (OR = 2.27; 95% CI, 2.11-2.44). The final model predicted risk of discharge to postacute care with excellent accuracy (C statistic = 0.924) and calibration (Brier score = 0.05). CONCLUSIONS AND RELEVANCE Individualized risk of discharge to postacute care can be predicted with excellent accuracy. This outcome will be incorporated into the ACS NSQIP Surgical Risk Calculator.

Assessment of non‐surgical versus surgical therapy for localized hepatocellular carcinoma

Localized hepatocellular carcinoma (HCC) in patients with adequate liver function is typically treated with resection. Non‐surgical modalities including trans‐arterial embolization have emerged as options for intermediate/advanced HCC. Hypothesizing that non‐surgical techniques have expanded to localized disease, we examined treatment patterns, factors associated with surgical therapy, and the impact of modality on survival.

Risk prediction tools in surgical oncology

Healthcare has increasingly focused on patient engagement and shared decision‐making. Decision aids can promote engagement and shared decision making by providing patients and their providers with care options and outcomes. This article discusses decision aids for surgical oncology patients. Topics include: short‐term risk prediction following surgery, long‐term risk prediction of survival and recurrence, the combination of short‐ and long‐term risk prediction to help guide treatment choice, and decision aid usability, transparency, and accessibility. J. Surg. Oncol. 2014 110:500–508.

Surgical Guidelines for Perioperative Management of Older Adults: What Geriatricians Need to Know

A multidisciplinary panel of experts representing surgery, anesthesia, and geriatrics recently published guidelines for surgeons on the optimal perioperative management of older adults, including recommendations on postoperative recovery and posthospital transitions of care. Geriatricians have an important role in the care for older adults in the preoperative period as older adults consider surgical options and prepare for surgical procedures, during the perioperative period as inpatient consultants, and in the postoperative period as older adults transition to rehabilitation facilities or to home. This article outlines the perioperative surgical guidelines and describes how they apply to the role of the geriatrician in the care of older adults during the perioperative period.

Impact of gastrectomy procedural complexity on surgical outcomes and hospital comparisons

BACKGROUND Most risk adjustment approaches adjust for patient comorbidities and the primary procedure. However, procedures done at the same time as the index case may increase operative risk and merit inclusion in adjustment models for fair hospital comparisons. Our objectives were to evaluate the impact of surgical complexity on postoperative outcomes and hospital comparisons in gastric cancer surgery. METHODS Patients who underwent gastric resection for cancer were identified from a large clinical dataset. Procedure complexity was characterized using secondary procedure CPT codes and work relative value units (RVUs). Regression models were developed to evaluate the association between complexity variables and outcomes. The impact of complexity adjustment on model performance and hospital comparisons was examined. RESULTS Among 3,467 patients who underwent gastrectomy for adenocarcinoma, 2,171 operations were distal and 1,296 total. A secondary procedure was reported for 33% of distal gastrectomies and 59% of total gastrectomies. Six of 10 secondary procedures were associated with adverse outcomes. For example, patients who underwent a synchronous bowel resection had a higher risk of mortality (odds ratio [OR], 2.14; 95% CI, 1.07-4.29) and reoperation (OR, 2.09; 95% CI, 1.26-3.47). Model performance was slightly better for nearly all outcomes with complexity adjustment (mortality c-statistics: standard model, 0.853; secondary procedure model, 0.858; RVU model, 0.855). Hospital ranking did not change substantially after complexity adjustment. CONCLUSION Surgical complexity variables are associated with adverse outcomes in gastrectomy, but complexity adjustment does not affect hospital rankings appreciably.

Uncommon Diverticular Disease

&NA; This article describes the epidemiology, pathogenesis, diagnosis, and treatment of three rare variants of diverticular disease: cecal and right‐sided colonic diverticula, giant colonic diverticula, and small bowel diverticula.