Estimating Risk of Postsurgical General and Geriatric Complications Using the VESPA Preoperative Tool | Geriatrics | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Elixhauser  A, Andrews  RM.  Profile of inpatient operating room procedures in US hospitals in 2007.  Arch Surg. 2010;145(12):1201-1208.PubMedGoogle ScholarCrossref
Etzioni  DA, Liu  JH, Maggard  MA, O’Connell  JB, Ko  CY.  Workload projections for surgical oncology: will we need more surgeons?  Ann Surg Oncol. 2003;10(9):1112-1117.PubMedGoogle ScholarCrossref
Harari  D, Hopper  A, Dhesi  J, Babic-Illman  G, Lockwood  L, Martin  F.  Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients.  Age Ageing. 2007;36(2):190-196.PubMedGoogle ScholarCrossref
Makary  MA, Segev  DL, Pronovost  PJ,  et al.  Frailty as a predictor of surgical outcomes in older patients.  J Am Coll Surg. 2010;210(6):901-908.PubMedGoogle ScholarCrossref
Dasgupta  M, Rolfson  DB, Stolee  P, Borrie  MJ, Speechley  M.  Frailty is associated with postoperative complications in older adults with medical problems.  Arch Gerontol Geriatr. 2009;48(1):78-83.PubMedGoogle ScholarCrossref
Hirth  VA, Eleazer  GP, Dever-Bumba  M.  A step toward solving the geriatrician shortage.  Am J Med. 2008;121(3):247-251.PubMedGoogle ScholarCrossref
Section for Enhancing Geriatric Understanding and Expertise Among Surgical and Medical Specialists (SEGUE), American Geriatrics Society.  Retooling for an aging America: building the healthcare workforce: a white paper regarding implementation of recommendation 4.2 of this Institute of Medicine Report of April 14, 2008, that ‘All licensure, certification and maintenance of certification for healthcare professionals should include demonstration of competence in care of older adults as a criterion.’.  J Am Geriatr Soc. 2011;59(8):1537-1539.PubMedGoogle ScholarCrossref
Malani  PN.  Functional status assessment in the preoperative evaluation of older adults.  JAMA. 2009;302(14):1582-1583.PubMedGoogle ScholarCrossref
Kothari  A, Phillips  S, Bretl  T, Block  K, Weigel  T.  Components of geriatric assessments predict thoracic surgery outcomes.  J Surg Res. 2011;166(1):5-13.PubMedGoogle ScholarCrossref
Pol  RA, van Leeuwen  BL, Visser  L,  et al.  Standardised frailty indicator as predictor for postoperative delirium after vascular surgery: a prospective cohort study.  Eur J Vasc Endovasc Surg. 2011;42(6):824-830.PubMedGoogle ScholarCrossref
Robinson  TN, Wallace  JI, Wu  DS,  et al.  Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient.  J Am Coll Surg. 2011;213(1):37-42.PubMedGoogle ScholarCrossref
Robinson  TN, Eiseman  B, Wallace  JI,  et al.  Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.  Ann Surg. 2009;250(3):449-455.PubMedGoogle Scholar
Robinson  TN, Wu  DS, Stiegmann  GV, Moss  M.  Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults.  Am J Surg. 2011;202(5):511-514.PubMedGoogle ScholarCrossref
Harrington  MB, Kraft  M, Grande  LJ, Rudolph  JL.  Independent association between preoperative cognitive status and discharge location after cardiac surgery.  Am J Crit Care. 2011;20(2):129-137.PubMedGoogle ScholarCrossref
Cronin  J, Livhits  M, Mercado  C,  et al.  Quality improvement pilot program for vulnerable elderly surgical patients.  Am Surg. 2011;77(10):1305-1308.PubMedGoogle Scholar
American College of Surgeons. ACS NSQIP/AGS best practice guidelines: optimal preoperative assessment of the geriatric surgical patient. programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx. Accessed June 28, 2017.
Hall  DE, Arya  S, Schmid  KK,  et al.  Development and initial validation of the Risk Analysis Index for measuring frailty in surgical populations.  JAMA Surg. 2017;152(2):175-182.PubMedGoogle ScholarCrossref
Katz  S, Ford  AB, Moskowitz  RW, Jackson  BA, Jaffe  MW.  Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function.  JAMA. 1963;185(12):914-919.PubMedGoogle ScholarCrossref
Lawton  MP, Brody  EM.  Assessment of older people: self-maintaining and instrumental activities of daily living.  Gerontologist. 1969;9(3):179-186.PubMedGoogle ScholarCrossref
Podsiadlo  D, Richardson  S.  The timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons.  J Am Geriatr Soc. 1991;39(2):142-148.PubMedGoogle ScholarCrossref
Kroenke  K, Spitzer  RL, Williams  JB.  The Patient Health Questionnaire-2: validity of a two-item depression screener.  Med Care. 2003;41(11):1284-1292.PubMedGoogle ScholarCrossref
Borson  S, Scanlan  J, Brush  M, Vitaliano  P, Dokmak  A.  The Mini-Cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly.  Int J Geriatr Psychiatry. 2000;15(11):1021-1027.PubMedGoogle ScholarCrossref
Campbell  DA  Jr, Englesbe  MJ, Kubus  JJ,  et al.  Accelerating the pace of surgical quality improvement: the power of hospital collaboration.  Arch Surg. 2010;145(10):985-991.PubMedGoogle ScholarCrossref
Inouye  SK, Leo-Summers  L, Zhang  Y, Bogardus  ST  Jr, Leslie  DL, Agostini  JV.  A chart-based method for identification of delirium: validation compared with interviewer ratings using the Confusion Assessment Method.  J Am Geriatr Soc. 2005;53(2):312-318.PubMedGoogle ScholarCrossref
Healthcare Cost and Utilization Project. Clinical classifications software for services and procedures. Updated March 30, 2017. Accessed January 4, 2014.
Chow  WB, Rosenthal  RA, Merkow  RP, Ko  CY, Esnaola  NF; American College of Surgeons National Surgical Quality Improvement Program; American Geriatrics Society.  Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.  J Am Coll Surg. 2012;215(4):453-466.PubMedGoogle ScholarCrossref
McCarten  JR, Anderson  P, Kuskowski  MA, McPherson  SE, Borson  S.  Screening for cognitive impairment in an elderly veteran population: acceptability and results using different versions of the Mini-Cog.  J Am Geriatr Soc. 2011;59(2):309-313.PubMedGoogle ScholarCrossref
Charlson  M, Szatrowski  TP, Peterson  J, Gold  J.  Validation of a combined comorbidity index.  J Clin Epidemiol. 1994;47(11):1245-1251.PubMedGoogle ScholarCrossref
Charlson  ME, Pompei  P, Ales  KL, MacKenzie  CR.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.  J Chronic Dis. 1987;40(5):373-383.PubMedGoogle ScholarCrossref
Birim  O, Maat  AP, Kappetein  AP, van Meerbeeck  JP, Damhuis  RA, Bogers  AJ.  Validation of the Charlson Comorbidity Index in patients with operated primary non-small cell lung cancer.  Eur J Cardiothorac Surg. 2003;23(1):30-34.PubMedGoogle ScholarCrossref
Suidan  RS, Leitao  MM  Jr, Zivanovic  O,  et al.  Predictive value of the Age-Adjusted Charlson Comorbidity Index on perioperative complications and survival in patients undergoing primary debulking surgery for advanced epithelial ovarian cancer.  Gynecol Oncol. 2015;138(2):246-251.PubMedGoogle ScholarCrossref
Fowler  JE  Jr, Terrell  FL, Renfroe  DL.  Co-morbidities and survival of men with localized prostate cancer treated with surgery or radiation therapy.  J Urol. 1996;156(5):1714-1718.PubMedGoogle ScholarCrossref
Kieszak  SM, Flanders  WD, Kosinski  AS, Shipp  CC, Karp  H.  A comparison of the Charlson Comorbidity Index derived from medical record data and administrative billing data.  J Clin Epidemiol. 1999;52(2):137-142.PubMedGoogle ScholarCrossref
Inouye  SK, Peduzzi  PN, Robison  JT, Hughes  JS, Horwitz  RI, Concato  J.  Importance of functional measures in predicting mortality among older hospitalized patients.  JAMA. 1998;279(15):1187-1193.PubMedGoogle ScholarCrossref
Centers for Medicare & Medicaid Services. PFS relative value files. Accessed July 20, 2016.
Bilimoria  KY, Liu  Y, Paruch  JL,  et al.  Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons.  J Am Coll Surg. 2013;217(5):833-842.e3.PubMedGoogle ScholarCrossref
Suskind  AM, Walter  LC, Jin  C,  et al.  Impact of frailty on complications in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database.  BJU Int. 2016;117(5):836-842.PubMedGoogle ScholarCrossref
Isik  O, Okkabaz  N, Hammel  J, Remzi  FH, Gorgun  E.  Preoperative functional health status may predict outcomes after elective colorectal surgery for malignancy.  Surg Endosc. 2015;29(5):1051-1056.PubMedGoogle ScholarCrossref
Hung  WW, Ross  JS, Boockvar  KS, Siu  AL.  Recent trends in chronic disease, impairment and disability among older adults in the United States.  BMC Geriatr. 2011;11:47.PubMedGoogle ScholarCrossref
Tinetti  ME, Mendes de Leon  CF, Doucette  JT, Baker  DI.  Fear of falling and fall-related efficacy in relationship to functioning among community-living elders.  J Gerontol. 1994;49(3):M140-M147.PubMedGoogle ScholarCrossref
Thomassen  Ø, Storesund  A, Søfteland  E, Brattebø  G.  The effects of safety checklists in medicine: a systematic review.  Acta Anaesthesiol Scand. 2014;58(1):5-18.PubMedGoogle ScholarCrossref
Siriussawakul  A, Nimmannit  A, Rattana-arpa  S, Chatrattanakulchai  S, Saengtawan  P, Wangdee  A.  Evaluating compliance with institutional preoperative testing guidelines for minimal-risk patients undergoing elective surgery.  Biomed Res Int. 2013;2013:835426.PubMedGoogle ScholarCrossref
Original Investigation
December 2017

Estimating Risk of Postsurgical General and Geriatric Complications Using the VESPA Preoperative Tool

Author Affiliations
  • 1Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
  • 2Geriatric Research Education Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
  • 3Department of Surgery, University of California, San Francisco
  • 4Department of Surgery, University of Michigan, Ann Arbor
  • 5Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
JAMA Surg. 2017;152(12):1126-1133. doi:10.1001/jamasurg.2017.2635
Key Points

Question  Can a short, functional, geriatric assessment scale (<10 minutes) administered by surgical nonphysician staff estimate risk of postsurgical complications, including traditional postoperative occurrences and novel geriatric outcomes, such as delirium and falls?

Findings  In this large cohort study of 736 patients 70 years of age or older, this tool estimated risk of postoperative complications, including difficulties with activities of daily living, inability to manage self-care, and number of comorbidities, with excellent statistical fit.

Meaning  Older patients undergoing elective surgery are at more risk than younger patients of postsurgical complications, but those at higher risk can be efficiently identified for closer monitoring.


Importance  As greater numbers of older patients seek elective surgery, one approach to preventing postoperative complications is enhanced assessment of risks during preoperative evaluation.

Objective  To determine whether a geriatric assessment tool can be implemented in a preoperative clinic and can estimate risk of postoperative complications.

Design, Setting, and Participants  In this prospective cohort study, patients 70 years of age or older were assessed in a preoperative clinic for elective surgery from July 9, 2008, to January 5, 2011. Patients were screened using the Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA) tool developed for this study. Patients were assessed on 5 preoperative activities of daily living recommended by the American College of Surgeons (bathing, transferring, dressing, shopping, and meals), history of falling or gait impairment, and depressive symptoms (2-item Patient Health Questionnaire). Patients also underwent a brief cognitive examination (Mini-Cog) and gait and balance assessment (Timed Up and Go test). A novel question was also asked as to whether patients expected they could manage themselves alone after discharge. Comorbidities and work-related relative value units (categorized into low, moderate, and high tertiles) were also collected. Multivariable logistic regression was performed to estimate risk of postoperative complications. Sustainability of VESPA over time was also evaluated. Medical record review was performed from December 11, 2012, to October 2, 2015, and data analysis was performed from November 15, 2015, to May 18, 2016.

Main Outcomes and Measures  Postoperative surgical and geriatric complications.

Results  Of the 770 patients evaluated, 736 (384 women and 352 men; mean [SD] age, 77.7 [5.7] years) underwent 740 operative procedures; of these patients, 711 had complete data for multivariable analysis. In our sample, 105 patients (14.3%) reported 1 or more difficulties with the 5 activities of daily living, and 270 of 707 patients (38.2%) foresaw themselves unable to manage self-care alone. A total of 131 of 740 patients had geriatric complications, and 114 of 740 patients had surgical complications; 187 of 740 patients (25.3%) had either geriatric or surgical complications. On multivariable analysis, the number of difficulties with activities of daily living (odds ratio [OR], 1.3; 95% CI, 1.0-1.6), anticipated difficulty with postoperative self-care (OR, 1.6; 95% CI, 1.0-2.2), Charlson Comorbidity score of 2 or more vs less than 2 (OR, 1.5; 95% CI, 1.0-2.3), male sex (OR, 1.6; 95% CI, 1.1-2.3), and work-related relative value units (moderate vs low: OR, 1.9; 95% CI, 1.1-3.3; high vs low: OR, 8.8; 95% CI, 5.3-14.5) were independently associated with postoperative complications (overall model area under the receiver operating characteristic curve, 0.77). With these results, a whole-point VESPA score used alone to estimate risk of complications also demonstrated excellent fit (area under the curve, 0.76).

Conclusions and Relevance  Preoperative assessment of older geriatric patients is feasible in the general preoperative clinic and can help identify patients at higher risk of postoperative complications.