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Original Investigation
February 12, 2020

Clinical Effectiveness of the Elder-Friendly Approaches to the Surgical Environment Initiative in Emergency General Surgery

Author Affiliations
  • 1Department of Surgery, Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada
  • 2Department of Critical Care Medicine, Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada
  • 3Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  • 4Department of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 5Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  • 6Aberhart Centre, Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
  • 7Department of Surgery, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
JAMA Surg. Published online February 12, 2020. doi:10.1001/jamasurg.2019.6021
Key Points

Question  Will a novel elder-friendly surgical care model reduce major complications and death in an emergency setting?

Findings  In this nonrandomized controlled study of 684 participants 65 years or older, in-hospital major complications or death decreased by 19% at the intervention site, which is clinically meaningful.

Meaning  This study suggests that an elder-friendly approach to the surgical environment may be clinically effective in an emergency setting, and implementation in other surgical specialties may be warranted.

Abstract

Importance  Older adults, especially those with frailty, have a higher risk for complications and death after emergency surgery. Acute Care for the Elderly models have been successful in medical wards, but little evidence is available for patients in surgical wards.

Objectives  To develop and assess the effect of an Elder-Friendly Approaches to the Surgical Environment (EASE) model in an emergency surgical setting.

Design, Setting, and Participants  This prospective, nonrandomized, controlled before-and-after study included patients 65 years or older who presented to the emergency general surgery service of 2 tertiary care hospitals in Alberta, Canada. Transfers from other medical services, patients undergoing elective surgery or with trauma, and nursing home residents were excluded. Of 6795 patients screened, a total of 684 (544 in the nonintervention group and 140 in the intervention group) were included. Data were collected from April 14, 2014, to March 28, 2017, and analyzed from November 16, 2018, through May 30, 2019.

Interventions  Integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices, promotion of patient-oriented rehabilitation, and early discharge planning.

Main Outcomes and Measures  Proportion of participants experiencing a major complication or death (composite) in the hospital, Comprehensive Complication Index, length of hospital stay, and proportion of participants who required an alternative level of care on discharge. Covariate-adjusted, within-site change scores were computed, and the overall between-site, preintervention-postintervention difference-in-differences (DID) were analyzed.

Results  A total of 684 patients were included in the analysis (mean [SD] age, 76.0 [7.6] years; 327 women [47.8%] and 357 men [52.2%]), of whom 139 (20.3%) were frail. At the intervention site, in-hospital major complications or death decreased by 19% (51 of 153 [33.3%] vs 19 of 140 [13.6%]; P < .001; DID P = .06), and mean (SE) Comprehensive Complication Index decreased by 12.2 (2.5) points (P < .001; DID P < .001). Median length of stay decreased by 3 days (10 [interquartile range (IQR), 6-17] days to 7 [IQR, 5-14] days; P = .001; DID P = .61), and fewer patients required an alternative level of care at discharge (61 of 153 [39.9%] vs 29 of 140 [20.7%]; P < .001; DID P = .11).

Conclusions and Relevance  To our knowledge, this is the first study to examine clinical outcomes associated with a novel elder-friendly surgical care delivery redesign. The findings suggest the clinical effectiveness of such an approach by reducing major complications or death, decreasing hospital stays, and returning patients to their home residence.

Trial Registration  ClinicalTrials.gov Identifier: NCT02233153

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