[Skip to Content]
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.
[Skip to Content Landing]
Original Investigation
May 2018

Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative

Author Affiliations
  • 1Department of Medicine, Duke University Medical Center, Durham, North Carolina
  • 2Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 3Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
  • 4Department of Medicine, University of Texas Southwestern Medical Center, Dallas
  • 5Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
  • 6Department of Surgery, Duke University Medical Center, Durham, North Carolina
JAMA Surg. 2018;153(5):454-462. doi:10.1001/jamasurg.2017.5513
Key Points

Question  Do older patients undergoing elective abdominal surgery benefit from participation in coordinated interdisciplinary perioperative care with geriatrics experts?

Findings  In this quality improvement case-control study, compared with the control group, older adults participating in the Perioperative Optimization of Senior Health program experienced shorter lengths of stay, had lower readmission rates at 7 days and 30 days, and were more likely to be discharged home with self-care, while experiencing fewer mean number of complications despite higher rates of delirium.

Meaning  A comanagement program based on incorporation of geriatric principles and expertise for older adults facing elective abdominal surgery may improve outcomes for this growing high-risk population.


Importance  Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients.

Objective  To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization.

Design, Setting, and Participants  Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH.

Main Outcomes and Measures  Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets.

Results  One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, –1.06 to –4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, –0.13 to –0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes.

Conclusions and Relevance  Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.