Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Importance

Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown.

Objective

To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults.

Design, Setting, and Participants

This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020.

Main Outcomes and Measures

The primary outcome was parathyroidectomy within 1 year of diagnosis.

Results

Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]).

Conclusions and Relevance

In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.

Derivation, Validation, Sustained Performance, and Clinical Impact of an Electronic Medical Record-Based Perioperative Delirium Risk Stratification Tool

BACKGROUND

Postoperative delirium is an important problem for surgical inpatients and was the target of a multidisciplinary quality improvement project at our institution. We developed and tested a semiautomated delirium risk stratification instrument, Age, WORLD backwards, Orientation, iLlness severity, Surgery-specific risk (AWOL-S), in 3 independent cohorts from our tertiary care hospital and describe its performance characteristics and impact on clinical care.

METHODS

The risk stratification instrument was derived with elective surgical patients who were admitted at least overnight and received at least 1 postoperative delirium screen (Nursing Delirium Screening Scale [NuDESC] or Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]) and preoperative cognitive screening tests (orientation to place and ability to spell WORLD backward). Using data pragmatically collected between December 7, 2016, and June 15, 2017, we derived a logistic regression model predicting probability of delirium in the first 7 postoperative hospital days. A priori predictors included age, cognitive screening, illness severity or American Society of Anesthesiologists physical status, and surgical delirium risk. We applied model odds ratios to 2 subsequent cohorts ("validation" and "sustained performance") and assessed performance using area under the receiver operator characteristic curves (AUC-ROC). A post hoc sensitivity analysis assessed performance in emergency and preadmitted patients. Finally, we retrospectively evaluated the use of benzodiazepines and anticholinergic medications in patients who screened at high risk for delirium.

RESULTS

The logistic regression model used to derive odds ratios for the risk prediction tool included 2091 patients. Model AUC-ROC was 0.71 (0.67-0.75), compared with 0.65 (0.58-0.72) in the validation (n = 908) and 0.75 (0.71-0.78) in the sustained performance (n = 3168) cohorts. Sensitivity was approximately 75% in the derivation and sustained performance cohorts; specificity was approximately 59%. The AUC-ROC for emergency and preadmitted patients was 0.71 (0.67-0.75; n = 1301). After AWOL-S was implemented clinically, patients at high risk for delirium (n = 3630) had 21% (3%-36%) lower relative risk of receiving an anticholinergic medication perioperatively after controlling for secular trends.

CONCLUSIONS

The AWOL-S delirium risk stratification tool has moderate accuracy for delirium prediction in a cohort of elective surgical patients, and performance is largely unchanged in emergent/preadmitted surgical patients. Using AWOL-S risk stratification as a part of a multidisciplinary delirium reduction intervention was associated with significantly lower rates of perioperative anticholinergic but not benzodiazepine, medications in those at high risk for delirium. AWOL-S offers a feasible starting point for electronic medical record-based postoperative delirium risk stratification and may serve as a useful paradigm for other institutions.

An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults

BACKGROUND

Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution.

METHODS

This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night.

RESULTS

During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline.

CONCLUSIONS

A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.

Preoperative Depressive Symptoms Associated with Poor Functional Recovery after Surgery

BACKGROUND/OBJECTIVES

Depression screening and treatment for older adults are recommended in Age-Friendly Health Systems. Few studies have evaluated the association between depressive symptoms and postoperative functioning. We aimed to determine the association between varying levels of depressive symptoms in the preoperative setting with postoperative functional recovery.

DESIGN

Prospective cohort study.

SETTING

Two academic hospitals in Boston, Massachusetts.

PARTICIPANTS

Surgical patients aged 70 and older (N = 560).

MEASUREMENTS

Participants were assessed preoperatively and 1 year postoperatively. Preoperative evaluation included the 15-item short-form Geriatric Depression Scale (GDS). Results were categorized as low (GDS = 0-1), moderate (2-5), or high (6-15) symptom burden. Primary outcome was 1-year instrumental activities of daily living functional decline. Secondary outcomes included hospital stay longer than 5 days, discharge to post-acute care (PAC) facility, and readmission within 30 days.

RESULTS

Mean participant age was 76.6 ± 5 years, 58% were women, 81% underwent an orthopedic operation, 13% gastrointestinal, 6% vascular; 13% had functional decline at 1 year after their operation (by symptom burden: low = 5.5%; moderate = 14.8%, and high = 38.6%). After adjusting for age, sex, and comorbidity, those with moderate or high depressive symptoms demonstrated greater odds of functional decline at 1 year compared with those with a low symptom burden (moderate: adjusted odds ratio [AOR] = 2.7; 95% confidence interval [CI] = 1.3-5.3; high: AOR = 9.3; 95% CI = 4.2-20.6), discharge to PAC facility (moderate: AOR = 1.7; 95%CI = 1.2-2.6; high: AOR = 2.7; 95% CI = 1.4-5.1) but demonstrated no significant association with 30-day readmission or hospital length of stay longer than 5 days.

CONCLUSION

Greater burden of preoperative depressive symptoms is associated with increased likelihood of functional decline at 1 year after surgery and of discharge to PAC facility. Preoperative assessment of the burden of depressive symptoms in older adults undergoing elective surgery may be helpful in identifying patients at high risk of poor outcomes.

The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon

The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.

Living in a Food Desert is Associated with 30-day Readmission after Revascularization for Chronic Limb-Threatening Ischemia

BACKGROUND

Living in a food desert has been associated with increased cardiovascular risk; however, its impact on vascular surgery outcomes is unknown. This study hypothesized that living in a food desert would be associated with increased postoperative complications in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI).

METHODS

This was a single-center retrospective analysis of open and endovascular infrainguinal revascularization for CLTI between April 2013 and December 2015. A food desert was defined using the US Department of Agriculture's Food Access Research Atlas. Bivariate analyses were performed appropriate to the data. Binary logistic regression was performed assessing the association of food desert status with 30-day postoperative complications.

RESULTS

In total, 152 cases were included, of which 17% (n = 26) resided in food deserts. Patients in the food desert cohort were less likely to be low income (27% vs. 54%, P = 0.01). Living in a food desert was associated with increased 30-day readmission [(39% vs. 20%, P = 0.04), unadjusted OR: 2.5 (CI: 1.0-6.2)]. FD cases also had a higher proportion of wound complications [12 (46%) vs. 28 (22%), P = 0.01)]. The overall wound complication rate was 27% with the majority being due to infections (63%). On multivariable analysis, food desert status remained associated with increased odds of 30-day readmission (OR: 2.7, CI: 1.2-8.4, P = 0.047). Reasons for readmission in the food desert group were all due to wound complications (100% vs. 72%, P = 0.08).

CONCLUSIONS

Living in a food desert was associated with nearly three times the odds of 30-day readmission after lower extremity revascularization for CLTI. This increase in readmission may be explained through increased wound complications. These findings support considering access to healthy food as a potential modifiable risk factor for adverse outcomes, particularly in CLTI revascularization.

Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery

Importance

More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.

Objective

To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery.

Design, Setting, and Participants

Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.

Exposures

Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.

Main Outcomes and Measures

Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors.

Results

Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%).

Conclusions and Relevance

In this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.

Patient complexity by surgical specialty does not correlate with work relative value units

BACKGROUND

Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units.

STUDY DESIGN

The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units.

RESULTS

Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units.

CONCLUSION

Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.

Is there a role for specialized geriatric centers in treating geriatric cancer patients?

As the population with colorectal cancer ages, the tailored approach required to manage older patients becomes all the more important for all providers and institutions treating colorectal cancer to adopt and improve the outcomes and well-being of this important and increasingly prevalent population. Joint guidelines from the American College of Surgeons and American Geriatric Association should be followed. Older cancer patients undergoing colorectal cancer surgery should be referred to centers with expertise in minimally invasive surgery. Likewise, older rectal cancer patients should be referred to centers with expertise in treating rectal cancer.

Time Spent Away from Home in the Year Following High-Risk Cancer Surgery in Older Adults

OBJECTIVES

To understand where older adults spend time (at home, in the hospital, or in a nursing home) in the year following high-risk cancer surgery.

DESIGN

Retrospective cohort study.

SETTING

Medicare beneficiaries using data from Medicare Inpatient claims to ascertain hospital days and the Minimum Data Set to ascertain nursing home days.

PARTICIPANTS

Beneficiaries who underwent high-risk cancer surgery (cystectomy, pancreaticoduodenectomy, gastrectomy, or esophagectomy) were identified to determine cumulative time spent away from home in the year following surgery.

MEASUREMENTS

Adjusted percentages of time spent away from home (ie, days in a hospital or nursing home) were modeled for the year following surgery.

RESULTS

A total of 37 748 beneficiaries underwent high-risk cancer surgery during the study period, and 28.3% died within 1 year. Overall, beneficiaries spent 13.9 ± 26.2 days in the hospital (over 1.5 ± 2.0 hospital readmissions) and 37.2 ± 50.6 days in the nursing home (over 1.5 ± 1.0 admissions) in the year following surgery. Among beneficiaries who were alive and dead at 1 year, 18.5% and 30.1% of time was spent away from home, respectively. Beneficiaries who were initially discharged to a facility following surgery and died within 1 year spent 44.4% of their final year away from home.

CONCLUSION

Time spent away from home in the hospital and/or nursing home in the year following high-risk cancer surgery is substantial among Medicare beneficiaries. This information is crucial in counseling patients on postoperative expectations and may additionally influence preoperative decision making. J Am Geriatr Soc 68:505-510, 2020.

GERIATRIC MEASURES AS PREDICTORS OF 1-YEAR MORTALITY IN MAJOR SURGERY PATIENTS

A growing proportion of older adults are undergoing major surgery despite the higher risk of post-operative mortality. Geriatric measures (i.e. physical, cognitive, and psychosocial function) are often not included in studies evaluating post-operative outcomes in older adults. Our goal was to determine the association of geriatric measures and 1-year mortality in older adults after major surgery. We analyzed longitudinal data from the Health and Retirement Study linked to Medicare claims (N=1364 participants), age ≥ 65 and who underwent abdominal aortic aneurysm [AAA] repair, coronary artery bypass graft [CABG], or colectomy. Our outcome was mortality within 1 year of the major operation. Predictors included the following geriatric measures: dependence in activities of daily living (ADL), dependence in independent activities of daily living (IADL), mobility ability, and dementia, and depression. We analyzed using multivariate cox proportional hazard models. Mean participant age was 76±6 years, 56% were women, 11% underwent a AAA repair, 50% CABG, 40% colectomy; 18% died within 1 year of their major operation. After adjusting for age, comorbidity burden, surgical type, gender, race, wealth, income, and education, the following measures were significantly associated with 1-year mortality: depression (adjusted HR (aHR): 1.53, p=0.03), dementia (aHR: 1.90, p=0.03), >1 ADL dependence (aHR: 2.35, p<0.01), >1 IADL dependence (aHR: 1.95, p<0.01), and inability to walk several blocks (aHR: 1.69, p<0.01). In this cohort, 18% of participants who underwent major surgery died within 1 year and function, cognition, and psychological well-being were significantly associated with mortality. These measures should be incorporated into pre-operative assessment.

MEASUREMENT OF GERIATRIC SURGERY OUTCOMES IN A NATIONAL REGISTRY

The American College of Surgeons National Quality Improvement Program started a “Geriatric Pilot” in January 2014. This project has already collected 19 additional older adult specialty variables in more than 60,000 patients undergoing operations. Twenty-six medical centers participate from across North America. The variables collect information in the domains of cognition, function, mobility and decision-making. Variables are collected in both the pre- and post-operative settings. It is clear that the quality of surgical care cannot be limited to the immediate hospitalization. The pilot has recently expanded its use of longer-term outcomes and has begun collecting 30-day outcomes of functional status and living location.

Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents

Importance

Breast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood.

Objective

To assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type.

Design, Setting, and Participants

This study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018.

Main Outcomes and Measures

Functional status and death.

Results

From 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups.

Conclusions and Relevance

For female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.

Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations

Importance

Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.

Objective

To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.

Design, Setting, and Participants

A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.

Main Outcomes and Measures

The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.

Results

A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001).

Conclusions and Relevance

Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.

How Did We Get Here? A Broader View of the Postoperative Period

The decision to offer surgery to an older adult with medical comorbidities involves candid conversations between the surgeon, patient, and caregivers. Tools are available to physicians that facilitate patient empowerment. Beyond short-term risks, the conversation should include the potential for institutional discharge, functional and cognitive decline, and longer term mortality.

What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery

OBJECTIVES

Valued life activities are those activities an individual deems particularly important or meaningful. Surgery in older adults can affect their ability to perform valued activities, but data are lacking. We characterized these activities and assessed performance of them following surgery.

DESIGN

Retrospective observational study.

SETTING

Preoperative program for older adults undergoing elective surgery at an academic hospital.

PARTICIPANTS

Older adults (N = 194) in the program from February 2015 to February 2018.

MEASUREMENTS

A preoperative written questionnaire asked, "What are the activities that are most important to you to be able to do when you return home from surgery?" Participants could list up to three activities. Content analysis was used to develop domains of valued life activities and categorize responses. Postoperative questionnaires and medical records were used to determine ability to perform activities 6 months after surgery.

RESULTS

Of 194 participants (mean age = 74.9 ± 9.1 y), 57.7% were female; 33.5% had more than two comorbid conditions. We elicited 510 valued activities, with a mean of 2.6 (± .7) activities per participant. Content analysis revealed five categories: (1) recreational activities (28.9%); (2) mobility (24.9%); (3) activities of daily living (ADLs; 17.5%); (4) instrumental activities of daily living (IADLs; 16.9%); and (5) social activities (12.0%). Ultimately, 154 participants had surgery, of which 27.3% were unable to perform one of their valued activities at 6 months. Performance varied between activity categories; 91.9% of mobility activities, 90.8% of ADLs, 80.3% of IADLs, 77.3% of social activities, and 65.5% of recreational activities were able to be performed after surgery.

CONCLUSION

Older adults expressed a wide range of valued life activities. More than one-quarter were unable to engage in at least one valued life activity after surgery, with recreation the most commonly affected. Assessment of valued life activities should be incorporated into the perioperative management of older adults. J Am Geriatr Soc 67:2305-2310, 2019.

The impact of frailty on treatment for overactive bladder in older adults

AIMS

To examine the impact of frailty on treatment outcomes for overactive bladder (OAB) in older adults starting pharmacotherapy, onabotulinumtoxinA, and sacral neuromodulation.

METHODS

This is a prospective study of men and women age ≥60 years starting pharmacotherapy, onabotulinumtoxinA, or sacral neuromodulation. Subjects were administered questionnaires at baseline and again at 1- and 3-months. Frailty was assessed at baseline using the timed up and go test (TUGT), whereby a TUGT time of ≥12 seconds was considered to be slow, or frail. Response to treatment was assessed using the overactive bladder symptom score (OABSS) and the OAB-q SF (both Bother and HRQOL subscales). Information on side effects/adverse events was also collected. Mixed effects linear modeling was used to model changes in outcomes over time both within and between groups.

RESULTS

A total of 45 subjects enrolled in the study, 40% (N = 18) of whom had a TUGT ≥12 seconds. Both TUGT groups demonstrated improvement in OAB symptoms over time and there were no statistically significant differences in these responses per group (all P-values >.05). Similar trends were found for both OAB-q SF Bother and OAB-q SF HRQOL questionnaire responses. Side effects and adverse events were not significantly different between groups (all P's >.05).

CONCLUSIONS

Adults ≥60 years of age starting second- and third-line treatments for OAB, regardless of TUGT time, demonstrated improvement in OAB symptoms at 3 months. These findings suggest that frail older adults may receive comparable benefit and similar rates of side effects compared with less frail older individuals.

The Association Between Race and Frailty in Older Adults Presenting to a Nononcologic Urology Practice

OBJECTIVE

To explore whether there is an association between nonwhite race and frailty among older adults presenting to an academic nononcologic urology practice.

MATERIALS AND METHODS

This is a prospective study of individuals ages ≥65years presenting to a nononcologic urology practice between December 2015 and November 2016. All individuals had a Timed Up and Go Test (TUGT, where a slower TUGT time of ≥15 seconds is suggestive of frailty. TUGT times, race (white vs nonwhite), and other clinical data were extracted from the electronic medical record using direct queries. Multivariable logistic regression was used to identify the association between race and slower TUGT times while adjusting for age, gender, number of medications, body mass index, and number of urologic diagnoses.

RESULTS

Among the 1715 individuals in our cohort, 33.9% were of nonwhite race and 15.3% had TUGT ≥15 seconds. A higher percentage of nonwhite individuals had TUGT times ≥15 seconds compared to white individuals (23.6% vs 11.1%, P <.01). TUGT times ≥15 seconds were significantly associated with nonwhite race after adjusting for clinical factors (adjusted odds ratio 2.5, 95% confidence interval 1.8-3.3).

CONCLUSION

Among older adults presenting to an academic nononcologic urology practice, nonwhite race was associated with increased odds of frailty. A greater understanding of the relationship between race and frailty is needed to better address the needs of this vulnerable population.

Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established.

METHODS

We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005-2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation.

RESULTS

We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0-1 frailty traits), 19% with an intermediate mFI score (2-3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20-2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33-16.41; p < 0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28-5.25; p < 0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64-10.74; p = 0.003).

CONCLUSION

Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.