New Study Identifies Sources for Surgical Complications in Older Patients

Newswise — The elderly are more vulnerable to problems after a major surgical procedure than younger patients, but a team of investigators using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) suggest that one way to improve surgical results in this age group is to have hospitals expand their quality control guidelines to include more types of surgery-related complications.

The investigators reviewed almost 55,000 gastrointestinal operations (GI) at 121 hospitals participating in ACS NSQIP. Specifically, these operations involved the upper GI tract, the gall bladder, pancreas, and colon and rectum. Elderly patients were up to twice as likely to have complications related to the operation than younger patients. The mortality rate in the elderly group was three to almost seven times higher than the younger group, depending on the procedure. The results of this study have been published in the November issue of Archives of Surgery.

“We know that when older patients undergo extensive operations there is higher risk. This study was undertaken to help raise institutional awareness of specific complications after these operations in order to prevent or treat complications as early as possible,” explained study coauthor David J. Bentrem, MD, FACS, Harold L. and Margaret N. Method Research Professor in Surgery, Northwestern University Feinberg School of Medicine, Chicago.

However, this analysis departed from previous studies by focusing on the types of complications in the elderly and comparing those rates with those for younger patients. “Here we were able to really identify the specific complications that occur more frequently using standardized data from a number of hospitals,” according to Karl Y. Bilimoria, MD, MS former research fellow at the American College of Surgeons and general surgery resident at Northwestern University, Department of Surgery, Chicago, and a coauthor of the study.

The investigators reported that hospital quality measures for older patients having an operation typically concentrate on three types of risk: heart attack, surgical wound infections, and blood clots in the legs. The analysis determined that rates of complications from wound infections and blood clots were comparable in both elderly and younger patients, but that the elderly were significantly more susceptible to a heart attack, pneumonia, pulmonary embolism, respiratory failure, urinary tract infection, and renal failure. “Within the context of the expanding and aging population in the United States, this study is important because it highlights important issues for surgery in the elderly. Providers, both surgical and non-surgical, need to work together to identify best practices in this regard. The ACS NSQIP is taking important steps in this arena, working with leaders of such groups as the American Geriatrics Society,” said Clifford Y. Ko, MD, FACS, a study co-author, who is Director, American College of Surgeons Division of Research and Optimal Patient Care, assistant professor of surgery, University of California (Los Angeles), and attending surgeon at the West Los Angeles VA Hospital.

The report authors concluded that quality improvement initiatives need to include pulmonary and urologic complications in older patients. “The next step would be to try to get this information back to more hospitals, have more hospitals involved in NSQIP and receive risk-adjusted data based on these specific complications in comparison to other hospitals, and to give them an idea of where to focus their quality improvement efforts,” Dr. Bilimoria said.

In the coming months, according to Dr. Bilimoria, there will be a “risk estimator” through ACS NSQIP that will enable surgeons to evaluate risks before surgical procedures and to allow patients and physicians to make more informed decisions about the risks of surgery.

“Basically, surgeons can enter the risk factors of their patients preoperatively and identify the rates of these complications and discuss those with the patients,” said Dr. Bilimoria. “It’s one piece of decision making that can help guide the discussion about whether surgery should be done or whether the risk is too prohibitive.” These data would be available through ACS NSQIP in 2010, according to Dr. Bilimoria.

Previously, research from the ACS NSQIP program published in the Annals of Surgery showed that hospitals participating in the program reported significant improvements in patient morbidity and mortality. The ACS NSQIP program provides a prospective, peer-controlled, validated database of surgical outcomes based on clinical data, not claims data. Originally launched in the 1990s by the Veterans Health Administration, the program was piloted in private sector hospitals in 2001 by the American College of Surgeons in partnership with the Agency for Healthcare Research and Quality (AHRQ). The program was made available to all private sector hospitals in 2004. Today, nearly 250 hospitals participate in the program.

In addition to Drs. Ko, Bentrem, and Bilimoria, Mark E. Cohen, PhD (American College of Surgeons), and Denise My Hynes, RN, PhD (University of Illinois at Chicago, and Edward Hines Jr Veterans Affiars Hospital, Hines, IL) participated in the study. The study was supported by the American College of Surgeons Clinical Scholars in Residence program and the Department of Surgery, Feinberg School of Medicine, Northwestern University.

CITATION: Bentrem DJ, Cohen ME, Hynes DM, Ko CY, Bilimoria KY. Identification of specific quality improvement opportunities for elderly undergoing gastrointestinal surgery. Arch Surg. 2009;144(11):1013-1020.