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Tang VL, Dillon EC, Yang Y, et al. Advance Care Planning in Older Adults With Multiple Chronic Conditions Undergoing High-Risk Surgery. JAMA Surg. 2019;154(3):261–264. doi:10.1001/jamasurg.2018.4647
More than 4 million high-risk operations (those that are associated with ≥1% in-hospital mortality) are performed annually in the United States in patients 65 years or older.1 While operative risk has declined over time, many older adults, especially those with multiple chronic conditions, remain at high risk for postoperative morbidity (including loss of independence and/or functional decline) and mortality.2,3 Therefore, the American College of Surgeons and American Geriatric Society jointly recommend patients engage in advance care planning (ACP), which includes documenting a patient’s personal goals and values, treatment preferences, and surrogate decision maker.4 In this study, we determined the prevalence and patient characteristics associated with ACP documentation among elderly adults at any time prior to high-risk surgery.
We included patients 65 years and older who were evaluated at Sutter Health (Palo Alto Medical Foundation), from January 1, 2013, through December 31, 2014. Eligible individuals were those who had multiple chronic conditions (defined as a Charlson Comorbidity score >15) and who underwent a high-risk procedure (defined by validated surgical Current Procedural Terminology codes that are associated with an in-hospital mortality rate ≥1%1). This study was approved by the Sutter Health institutional review board. Demographic and clinical data were abstracted from electronic health records; no informed consent was needed.
The primary outcome of ACP documentation was abstracted from health records, because Palo Alto Medical Foundation collects this information in an electronic problem list. Palo Alto Medical Foundation uses an automated clinician reminder that is triggered when patients turn 65 years old and continues to fire at all appointments until completed. Documentation of ACP included the presence of either an advanced directive, a durable power of attorney for health care, or a physician order for life-sustaining treatment. In this study, no distinction was made as to the timing of ACP documentation as long as it was completed prior to the index surgery.
We conducted descriptive and comparative statistics (χ2 test for categorical variables) with Stata version 14.2 (StataCorp), considering P values less than .05 statistically significant. We assessed unadjusted and adjusted probability of ACP documentation across specific patient characteristics and used logistic regression to simultaneously adjust for a parsimonious selection of associated variables. We also reviewed 25 randomly selected electronic health records of patients who died within a year of surgery to assess whether any preoperative notes referenced the patient’s personal goals and values in developing the surgical care plan. We followed up all included patients from study inception to their death or December 31, 2014, whichever came first. Data analysis was conducted from November 2016 through October 2017.
Overall, 393 patients (mean [SD] age, 79.0 [7.8] years) met inclusion criteria (Table 1). Of the overall cohort, 101 (25.7%) had ACPs documented preoperatively. Among those who died within a year of surgery (n = 55 [14.0%]), only 17 (30.9%) had documentation. Mean (SD) time to death after surgery was 107 (104) days (range, 4-341 days).
In an adjusted analysis (Table 2), individuals 85 years or older were more likely to have ACP documentation than individuals aged 65 to 74 years (adjusted odds ratio [aOR], 2.00 [95% CI, 1.03-3.90]; P = .04). Similarly, patients with higher health care use (more than 8 office visits in the year before surgery) were more likely to have ACP documentation than those with lower use (0-3 such visits; aOR, 13.01 [95% CI, 4.07-41.64]; P < .001) and those with cognitive impairment, defined as a dementia or mild cognitive impairment diagnosis at the time of surgery were more likely to have ACP documentation than those without cognitive impairment (aOR, 6.12 [95% CI, 1.54-24.31]; P = .01).
On review of the 25 randomly selected records of patients who died within a year, 16 (64%) had preoperative notes. No ACP documentation was found in any of these records.
Among a cohort of 393 older adults with multiple chronic conditions who are undergoing high-risk surgery, 101 (25.7%) had preoperative ACP documentation, including only 17 of 55 decedents (30.9%). Yet in a prior study,6 52% of surgeons self-reported having had preoperative ACP discussions. High-risk populations in this study, including patients 85 years and older, those with dementia, and those with greater health care use, were more likely to have ACP documentation. However, all older adults with multiple chronic conditions undergoing high-risk surgery would benefit from having ACP completed with documentation in medical records. Future studies should address the timing of ACP to the surgical visit and the question of whether ACP affects surgical decision making or outcomes. Outreach, education, and system workflow changes to increase ACP engagement in elderly populations are essential to preparing patients and their families prior to potentially life-changing events.
Corresponding Author: Victoria L. Tang, MD, MAS, Division of Hospital Medicine, Department of Medicine, Veterans Affairs Medical Center, 4150 Clement St, Ste 181(G), San Francisco, CA 94121 (firstname.lastname@example.org).
Published Online: December 5, 2018. doi:10.1001/jamasurg.2018.4647
Author Contributions: Dr Dillon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Tang, Dillon, Tai-Seale, Sudore.
Acquisition, analysis, or interpretation of data: Tang, Dillon, Yang, Tai-Seale, Boscardin, Kata.
Drafting of the manuscript: Tang, Dillon.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Dillon, Yang, Boscardin.
Obtained funding: Tang, Dillon, Tai-Seale.
Administrative, technical, or material support: Dillon.
Supervision: Dillon, Tai-Seale, Sudore.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the National Institute on Aging Health Care Systems Research Network–Claude D. Pepper Older Americans Independence Centers Advancing Geriatric Infrastructure and Network Growth (AGING) Initiative (grants R24AG045050 and P30AG044281), National Institute on Aging Grants for Early Medical/Surgical Specialists’ Transition to Aging Research (grant R03AG056342), and University of California San Francisco Clinical and Translational Science Institute Career Development Program (CTSI KL2 grant KL2TR001870). In addition, this work was made possible by the facilities and resources of the Palo Alto Medication Foundation.
Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Meeting Presentations: Earlier versions of these findings were presented at the Health Care Systems Research Network Annual Conference; April 11, 2018; Minneapolis, Minnesota; International Association of Gerontology and Geriatrics World Congress; July 23, 2017; San Francisco, California; Advancing Geriatrics Infrastructure and Network Growth (AGING) Initiative webinar; February 12, 2018; New York, NY.