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To evaluate 30-day complications and 1-year mortality for older adults undergoing haemorrhoid surgery.This retrospective cohort study evaluated older adults (age 66+) undergoing haemorrhoid surgery using Medicare claims and the minimum data set (MDS). Long-stay nursing home residents were identified, and propensity score matched to community-dwelling older adults. Generalized estimating equation models were created to determine the adjusted relative risk of 30-day complications, length of stay (LOS), and 1-year mortality. Among nursing home residents, functional and cognitive status were evaluated using the MDS-activities of daily living (ADL) score and the Brief Instrument of Mental Status. Faecal continence status was evaluated among a subset of nursing home residents.A total of 3664 subjects underwent haemorrhoid surgery and were included in the analyses. Nursing home residents were at significantly higher risk for 30-day complications (52.3% vs. 32.9%, aRR 1.6 [95% CI: 1.5-1.7], p 0.001), and 1-year mortality (24.9% vs. 16.1%, aRR 1.6 [95% CI: 1.3-1.8], p 0.001). Functional and mental status showed an inflection point of decline around the time of the procedure, which did not recover to the baseline trajectory in the following year. Additionally, a subset of nursing home residents demonstrated worsening faecal incontinence.This study demonstrated high rates of 30-day complications and 1-year mortality among all older adults (yet significantly worse among nursing home residents). Ultimately, primary care providers and surgeons should carefully weigh the potential harms of haemorrhoid surgery in older adults living in a nursing home.

Activated T cells may express FOXP3. It is thought that FOXP3 is not a specific marker to determine regulatory T cells (Treg) in humans. Here, we examined the functional phenotype and cytokine profile of the in vitro induced FOXP3+ T cells, primary FOXP3+ and FOXP3- T cells in patients with ulcerative colitis and tumors including colon carcinoma, melanoma, hepatic carcinoma, ovarian carcinoma, pancreatic cancer, and renal cell carcinoma. We observed similar levels of suppressive capacity of primary FOXP3+ T cells in blood, tumors, and colitic tissues. Compared with primary FOXP3- T cells in the same microenvironment, these primary FOXP3+ T cells expressed minimal levels of effector cytokines, negligible amount of cytotoxic molecule granzyme B, and levels of suppressive molecules interleukin-10 and PD-1. Although the in vitro activated T cells expressed FOXP3, these induced FOXP3+ T cells expressed high levels of multiple effector cytokines and were not functionally suppressive. The data reinforce the fact that FOXP3 remains an accurate marker to define primary Tregs in patients with cancer and autoimmune disease. We suggest that the combination of FOXP3 and cytokine profile is useful for further functionally distinguishing primary Tregs from activated conventional T cells. [Cancer Res 2009;69(9):3995–4000]

Background Up to 30% of patients with ulcerative colitis will undergo surgery resulting in an ileal pouch-anal anastomosis (IPAA) or permanent end ileostomy (EI). We aimed to understand how patients decide between these two options. Methods We performed semi-structured interviews with ulcerative colitis patients who underwent surgery. Areas of questioning included the degree to which patients participated in decision-making, challenges experienced, and suggestions for improving the decision-making process. We analyzed the data using a directed content and thematic approach. Results We interviewed 16 patients ranging in age from 28 to 68 years. Nine were male, 10 underwent IPAA, and 6 underwent EI. When it came to participation in decision-making, 11 patients felt independently responsible for decision-making, 3 shared decision-making with the surgeon, and 2 experienced surgeon-led decision-making. Themes regarding challenges during decision-making included lack of support from family, lack of time to discuss options with the surgeon, and the overwhelming complexity of the decision. Themes for ways to improve decision-making included the need for additional information, the desire for peer education, and earlier consultation with a surgeon. Only 3 patients were content with the information used to decide about surgery. Conclusions Patients with ulcerative colitis who need surgery largely experience independence when deciding between IPAA and EI, but struggle with inadequate educational information and social support. Patients may benefit from early access to surgeons and peer guidance to enhance independence in decision-making. Preoperative educational materials describing surgical complications and postoperative lifestyle could improve decision-making and facilitate discussions with loved ones.

Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery.To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention.This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021.Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI).Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not.Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P.001).These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.

Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults.We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity.Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at90 days and having a higher care complexity were associated with prolonged use of gabapentin.More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.

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.

Author(s): Donovan, Anne L; Braehler, Matthias R; Robinowitz, David L; Lazar, Ann A; Finlayson, Emily; Rogers, Stephanie; Douglas, Vanja C; Whitlock, Elizabeth L; Anesthesia Resident Quality Improvement Committee | Abstract: BackgroundPostoperative 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.MethodsThis 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 l65 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.ResultsDuring 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.ConclusionsA perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.

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 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.

Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there is little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized.Cognitive impairment screening was prospectively performed for Veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment.Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, p=0.03), Black vs. White race (94% vs. 54%, p0.01), hypertension (66% vs. 31%, p=0.01), prior stroke/TIA (79% vs. 58%, p=0.03), diabetes treated with insulin (79% vs. 58%, p=0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, p=0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥ 70 years, diabetes treated with insulin, PTSD, and Black race.Many Veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.

Patients with Alzheimer's Disease and Related Dementias (ADRD) undergoing inpatient procedures represent a population at elevated risk for adverse outcomes including postoperative complications, mortality, and discharge to a higher level of care. Outcomes may be particularly poor in patients with ADRD undergoing high-risk procedures. We sought to determine traditional (e.g., 30-day mortality) and patient-centered (e.g., discharge disposition) outcomes in patients with ADRD undergoing high-risk inpatient procedures.This retrospective cohort study analyzed electronic health records linked to fee-for-service Medicare claims data at a tertiary care academic health system. All patients from a large multi-hospital health system undergoing high-risk inpatient procedures from October 1, 2015 to September 30, 2017 with continuous Medicare Parts A and B enrollment in the 12 months prior to and 90 days following the procedure were included.This study included 6779 patients. 536 (7.9%) had ADRD. A multivariable analysis of outcomes demonstrated higher risks for postoperative complications (OR 1.49, 95% CI 1.23-1.81) and 90-day mortality (OR 1.44 [95% CI 1.09-1.91]) in patients with ADRD compared to those without. Patients with ADRD were more likely to be discharged to a higher level of care (OR 1.70, 95% CI 1.32-2.18) and only 37.3% of patients admitted from home were discharged to home.Compared to those without ADRD, patients living with ADRD undergoing high-risk procedures have poor traditional and patient-centered outcomes including increased risks for 90-day mortality, postoperative complications, longer hospital lengths of stay, and discharge to a higher level of care. These data may be used by patients, their surrogates, and their physicians to help align surgical decision-making with health care goals.

PURPOSE: Sling surgery is the gold standard treatment for stress urinary incontinence in women. While data support the use of sling surgery in younger and middle-aged women, outcomes in older, frail women are largely unknown. MATERIALS AND METHODS: Data were examined for all Medicare beneficiaries ≥65 years who underwent sling surgery with or without concomitant prolapse repair from 2014 to 2016. Beneficiaries were stratified using the Claims-based Frailty Index (CFI) into four categories: not frail (CFI

Introduction: Peripheral arterial disease (PAD) is common among older adults and shares a pathophysiologic mechanism with vascular dementia, yet there remains a paucity of data about the prevalence of cognitive impairment (CI) in this population. The aim of this study was to estimate CI prevalence in a nationally representative sample of adults with PAD and identify independent risk factors for CI. Hypothesis: We hypothesized CI would be common and that risk factors would include advancing age. Methods: The U.S. Health and Retirement Study with Medicare Linkage and CI assessment was utilized for years 2000-2016. PAD was identified using ICD-9/10 and CPT codes. CI was defined using the Langa-Weir classification based on CI assessment within 2.5 years prior to first documented PAD diagnosis in the Medicare. Bivariate analysis for association with CI was performed appropriate to the data followed by multivariable logistic regression for the primary endpoint of CI. Results: Overall, 4,383 PAD individuals aged 65 and over at time of PAD diagnosis were included. Overall, 39% had CI. CI was associated with increasing age (p2 (p Conclusions: Cognitive impairment is common in adults living with PAD and is associated with age, race/ethnicity, education, depression, geriatric syndromes and functional status, similar to those without PAD. Given CI’s prevalence in individuals with PAD, future study is imperative to understand how CI impacts PAD related health. These findings can be used to risk stratify patients for CI screening.

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.

ImportanceAdvance care planning (ACP) prepares patients and caregivers for medical decision-making, yet it is underused in the perioperative surgical setting, particularly among older adults undergoing high-risk procedures who are at risk for postoperative complications. It is unknown what patient factors are associated with perioperative ACP documentation among older surgical patients.ObjectiveTo assess ACP documentation among high-risk patients 65 years and older undergoing elective surgery.Design, Setting, and ParticipantsIn this observational cohort study including 3671 patients 65 years and older undergoing elective surgery at a tertiary academic center in California, electronic health record data were linked to the National Surgical Quality Improvement Project outcomes data and the California statewide death registry. The study was conducted from January 1 to December 31, 2019. Data were analyzed from January to May 2022.ExposuresElective surgery requiring an inpatient admission.Main Outcomes and MeasuresACP documentation, defined as a discussion regarding goals of care documented in an ACP note, an advance directive, or a physician order for life-sustaining treatment (POLST) form, within 90 days before elective surgery requiring inpatient admission. Multivariate regression was performed to identify factors associated with missing ACP.ResultsAmong 3671 patients (median [IQR] age 72 [65-94] years; 1784 [48.6%] female; 401 [10.9%] Asian, 155 [4.2%] Black, 284 [7.7%] Latino/Latina, 2647 [72.1%] White, and 184 [5.0%] of other races or ethnicities, including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiple races or ethnicities, other, and unknown or declined to respond, combined owing to small numbers), 539 (14.7%) had ACP documentation in the 90-day presurgery window. Of these 539, 448 (83.1%) had advance directives, and 60 (11.1%) had POLST forms. The 30-day and 1-year mortality were 0.7% (n = 27) and 6.6% (n = 244), respectively. Missing ACP was significantly associated with male sex (adjusted odds ratio [aOR], 1.39; 95% CI, 1.14-1.69) and having a non-English preferred language (aOR, 1.78; 95% CI, 1.18-2.79). Medicare insurance was significantly associated with having ACP (aOR for missing ACP, 0.63; 95% CI, 0.40-0.95).Conclusions and RelevanceIn this study, perioperative ACP was uncommon, particularly in men, individuals with a non-English preferred language, and those without Medicare insurance coverage. The perioperative setting may represent a missed opportunity for ACP for older surgical patients. When addressing ACP for surgical patients, particular attention should be paid to overcoming language-related disparities.

INTRODUCTION AND OBJECTIVE:Surgery for bladder and bowel dysfunction is common among older adults, many of whom have additional vulnerabilities such as frailty and functional/cognitive decline. The...

Importance For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown. Objective To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery. Design, Setting, and Participants This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018. Interventions Patients received a question prompt list brochure with 11 questions that they might ask their surgeon. Main Outcomes and Measures For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted. Results Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%];P= .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%];P= .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%];P= .22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%];P= .77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively. Conclusions and Relevance Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively. Trial Registration ClinicalTrials.gov Identifier:NCT02623335

Background/objectives To compare surgical outcomes between vulnerable nursing home (NH) residents and matched community-dwelling older adults undergoing surgery for bladder and bowel dysfunction. Design Retrospective cohort study. Participants A total of 55,389 NH residents and propensity matched (based on procedure, age, sex, race, comorbidity, and year) community-dwelling older adults undergoing surgery for bladder and bowel dysfunction [female pelvic surgery, transurethral resection of the prostate, suprapubic tube placement, hemorrhoid surgery, rectal prolapse surgery]. Individuals were identified using Medicare claims and the Minimum Data Set (MDS) for NH residents between 2014 and 2016. Measurements Thirty-day complications, 1-year mortality, and weighted changes in healthcare resource utilization (hospital admissions, emergency room visits, office visits) in the year before and after surgery. Results NH residents demonstrated statistically significant increased risk of 30-day complications [60.1% v. 47.2%; RR 1.3 (95% CI 1.3-1.3)] and 1-year mortality [28.9% vs. 21.3%; RR 1.4 (95% CI 1.3-1.4)], compared to community-dwelling older adults. NH residents also demonstrated decreased healthcare resource utilization, compared to community-dwelling older adults, changing from 3.9 to 1.9 (vs.1.1 to 1.0) hospital admissions, 11 to 10.1 (vs. 9 to 9.7) office visits, and 3.4 to 2.2 (vs. 1.9 to 1.9) emergency room visits from the year before to after surgery. Conclusion Despite matching on several important clinical characteristics, NH residents demonstrated increased rates of 30-day complications and 1-year mortality after surgery for bowel and bladder dysfunction, while demonstrating decreased healthcare resource utilization. These mixed findings suggest that outcomes may be more varied among vulnerable older adults and warrant further investigation.

OBJECTIVE There is an increasing emphasis on surgical trainees learning how to appropriately provide care for the geriatric patient. We hypothesized that little published formal curriculum on the topic exists. We sought to perform a scoping review to test this hypothesis. DESIGN PubMed, OVID Medline, and EMBASE databases were queried from inception, supplemented by hand search of references and the grey literature. Included English language abstracts and articles described trainee perceptions of geriatric patients and/or description of dedicated geriatric curricula for trainees. RESULTS There were 21 included abstracts or papers, which were categorized into 8 survey-based studies, 6 descriptions of curricular design, and 7 interventional studies with pre- and post-intervention knowledge tests. General surgery residents were most frequently included. Self-rated confidence and comfort were typically higher than objective measures of resident performance in the care of geriatric patients. Residents were commonly unaware of the standardized assessment tools and recommendations that exist. Medication and delirium management were frequently-identified topics posing the widest gaps in resident knowledge. CONCLUSION There are few published examples of curricula on the care of geriatric patients for surgical trainees. More work is needed for the creation of specialty-specific and needs-based geriatric surgical curricula.

Background After serious postoperative complications, patients and families may experience conflict about goals of care. Methods We performed a multisite randomized clinical trial to test the effect of a question prompt list on postoperative conflict. We interviewed family members and patients age ≥60 who experienced serious complications. We used qualitative content analysis to analyze conflict and characterize patient experiences with complications. Results Fifty-six of 446 patients suffered a serious complication. Participants generally did not report conflict relating to postoperative treatments and expressed support for the care they received. We did not appreciate a difference in conflict between intervention and usual care. Respondents reported feeling unprepared for complications, witnessing heated interactions among team members, and a failure to develop trust for their surgeon preoperatively. Conclusion Postoperative conflict following serious complications is well described but its incidence may be low. Nonetheless, patient and family observations reveal opportunities for improvement.

Author(s): Whitlock, Elizabeth L; Braehler, Matthias R; Kaplan, Jennifer A; Finlayson, Emily; Rogers, Stephanie E; Douglas, Vanja; Donovan, Anne L | Abstract: BackgroundPostoperative 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.MethodsThe 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.ResultsThe 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.ConclusionsThe 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.

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.

PURPOSE: To compare short- and long-term outcomes between nursing home residents and matched community-dwelling older adults undergoing surgery for pelvic organ prolapse (POP). MATERIALS AND METHODS: This retrospective cohort study evaluates women ≥65 years of age undergoing different types of POP repairs (anterior/posterior, apical, and colpocleisis) between 2007 and 2012 using Medicare claims and the Minimum Data Set for Nursing Home Residents. Long-stay nursing home residents were identified and propensity score matched (1:2) to community dwelling older individuals based on procedure type, age, race, and Charlson Score. Generalized Estimating Equation models were created to determine the relative risk (RR) of hospital length of stay ≥3 days, 30-day complications, and 1-year mortality between the two groups. Kaplan Meier curves were created comparing 1-year mortality between groups. RESULTS: There were 799 nursing home residents and 1598 matched community-dwelling older adults who underwent POP surgery and were included in our analyses. Nursing home residents demonstrated statistically significant increased risk for hospital length of stay ≥3 [38.9% vs 18.6%; adjusted RR 2.1 (95% CI 1.8–2.4)], 30-day complications [15.1% vs 3.8%; aRR 3.9 (95% CI 2.9–5.3)], and 1-year mortality [11.1% vs 3.2%; aRR 3.5 (95% CI 2.5–4.8)] compared to community-dwelling older adults. Kaplan Meier curves illustrated similar survival findings at 1-year [11.1% (95% CI 9.0%−13.3%) vs 3.2% (95% CI 2.3%−4.1%), p

BACKGROUND/OBJECTIVES: Older adults undergoing surgery face potential outcomes that can adversely impact their quality of life. For this reason, advance care planning (ACP) is a recommended component of preoperative care. An emerging opportunity to incorporate ACP is through preoperative optimization programs. This report details an innovative model of care, the Surgery Wellness Program (SWP), which utilizes a multidisciplinary team to develop and implement preoperative care plans for older adults and describes its impact on ACP engagement. DESIGN: Retrospective analysis of a clinical demonstration project. SETTING: A preoperative optimization program for older adults undergoing surgery at a 796-bed academic tertiary hospital. PARTICIPANTS: Older adults (N=131) who participated in the SWP from February 2015 to August 2017. INTERVENTION: All SWP patients met with a geriatrician who engaged them in a semi-structure ACP discussion. Trained medical and nurse practitioner students were used as health coaches who contact patients regularly to address and document ACP. MEASUREMENTS: Patient self-report of ACP engagement before and after participation in the SWP was determined with SWP geriatrician and health coach progress notes. Medical records were assessed for the presence of scanned documentation. Feasibility data on the number of health coach calls was collected. RESULTS: After completion of the program, the proportion of patients with a designated surrogate increased from 67% to 78% (p

Objectives To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions. Data source/study setting Primary data (ratings) were reported from 58 stakeholder organizations. Study design An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016. Data collection/extraction methods Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2). Principal findings In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3). Conclusions There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group.

We sought to determine whether frailty affects the type of pelvic organ prolapse surgery performed and the odds of postoperative complications.This is a retrospective cohort study of women who underwent obliterative and reconstructive surgery for pelvic organ prolapse in ACS (American College of Surgeons) NSQIP® (National Surgical Quality Improvement Program) from 2005 to 2013. We quantified frailty using NSQIP-FI (Frailty Index) and applied logistic regression models predicting the type of procedure (colpocleisis) and the odds of postoperative complications.We identified a total of 12,731 women treated with pelvic organ prolapse repair, of which 5.3% were colpocleisis procedures, from 2005 to 2013. Among women undergoing colpocleisis, the average age was 79.2 years and 28.5% had a NSQIP-FI of 0.18 or higher, indicating frailty. Women undergoing colpocleisis procedures had higher odds of being frail (NSQIP-FI 0.18 vs 0 OR 1.9, 95% CI 1.4-2.6) and were older (age 85+ vs less than 65 years OR 486.4, 95% CI 274.6-861.7). For all types of pelvic organ prolapse procedures, frailty increased the odds of complications (NSQIP-FI 0.18 vs 0 OR 2.8, 95% CI 1.8-3.0), after adjusting for age and type of pelvic organ prolapse procedure.For pelvic organ prolapse surgery, age rather than frailty is more strongly associated with the type of procedure performed. However, frailty is more strongly associated with postoperative complications than age. Furthermore, incorporating frailty into preoperative decision making is important to improve expectations and outcomes among older women considering pelvic organ prolapse surgery.

Trials of enhanced recovery programs suggest that multimodality pain regimens improve outcomes after colorectal surgery. We sought to determine whether patients receiving postoperative multimodality pain regimens would have shorter lengths of stay without an associated increase in readmission rate as compared to those receiving opioid-based pain regimens. Retrospective cohort study of adults who underwent elective colorectal surgery between January 1, 2006, and December 31, 2012, in a national hospital network participating in the Premier Perspective database. Patients were grouped into multimodality or opioid-based using postoperative medication charges. Primary outcome measures included length of stay and 30-day readmission rate. Among 91,936 patients, 38 per cent received multimodality pain regimens and 61 per cent received opioid-based regimens. After adjustment for patient and surgical characteristics, there was no difference in length of stay or cost, odds of readmission were 1.2 (95% confidence interval = 1.2–1.3, P < 0.001), and odds of mortality were 0.8 (95% confidence interval = 0.6–0.9, P < 0.001) in the multimodality group compared to nonopioid sparing. Our results were consistent in secondary analyses using propensity matching. Fewer than half of patients undergoing elective colorectal surgery in our cohort received multimodality pain regimens, and receipt of these medications was associated with mixed benefits in terms of length of stay, readmission, and mortality.

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.

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.

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.

Introduction: Opioids are routinely prescribed to manage acute postoperative pain, but changes in postoperative opioid prescribing associated with the marketing of long-acting opioids such as OxyContin have not been described in the surgical cohort. Methods: Using a large commercial claims data set, we studied postoperative opioid prescribing after selected common surgical procedures between 1994 and 2014. For each procedure and year, we calculated the mean postoperative morphine milligram equivalents (MME) filled on the index prescription and assessed the proportion of patients who filled a high-dose prescription (≥350 MME). We reported changes in postoperative opioid prescribing over time and identified predictors of filling a high-dose postoperative opioid prescription. Results: We identified 1,321,264 adult patients undergoing selected common surgical procedures between 1994 and 2014, of whom 80.3% filled a postoperative opioid prescription. One in five surgery patients filled a high-dose postoperative opioid prescription. Between 1994 and 2014, the mean MME filled increased by 145%, 84%, and 85% for lumbar laminectomy/laminotomy, total knee arthroplasty, and total hip arthroplasty, respectively. The procedures most likely to be associated with a high-dose opioid fill were all orthopaedic procedures (AOR 5.20 to 7.55, P < 0.001 for all). Patients whose postoperative opioid prescription included a long-acting formulation had the highest odds of filling a prescription that exceeded 350 MME (AOR 32.01, 95% CI, 30.23–33.90). Discussion: After the US introduction of long-acting opioids such as OxyContin, postoperative opioid prescribing in commercially insured patients increased in parallel with broader US opioid-prescribing trends, most notably among patients undergoing orthopaedic surgical procedures. The increase in the mean annual MME filled starting in the late 1990s was driven in part by the higher proportion of long-acting opioid formulations on the index postoperative opioid prescription filled by orthopaedic surgery patients.

Importance Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict. Objective To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. Design, Setting, and Participants This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat. Interventions A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. Main Outcomes and Measures Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient’s Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. Results Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74;P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35;P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80;P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59;P = .04) (nominal α = .01). Conclusions and Relevance The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly. Trial Registration ClinicalTrials.gov identifier:NCT02623335

IMPORTANCE: Postoperative delirium (POD) is a common condition for older adults, contributing to their functional decline. OBJECTIVE: To investigate the effectiveness of the Tailored, Family-Involved Hospital Elder Life Program (t-HELP) for preventing POD and functional decline in older patients after a noncardiac surgical procedure. DESIGN, SETTING, AND PARTICIPANTS: A 2-arm, parallel-group, single-blind, cluster randomized clinical trial was conducted from August 24, 2015, to February 28, 2016, on 6 surgical floors (gastric, colorectal, pancreatic, biliary, thoracic, and thyroid) of West China Hospital in Chengdu, China. Eligible participants (n = 281) admitted to each of the 6 surgical floors were randomized into a nursing unit providing t-HELP (intervention group) or a nursing unit providing usual care (control group). All randomized patients were included in the intention-to-treat analyses for the primary outcome of POD incidence. Statistical analysis was performed from April 3, 2016, to December 30, 2017. INTERVENTIONS: In addition to receiving usual care, all participants in the intervention group received the t-HELP protocols, which addressed each patient’s risk factor profile. Besides nursing professionals, family members and paid caregivers were involved in the delivery of many of the program interventions. MAIN OUTCOMES AND MEASURES: The primary outcome was the incidence of POD, evaluated with the Confusion Assessment Method. Secondary outcomes included the pattern of functional and cognitive changes (activities of daily living [ADLs], instrumental activities of daily living [IADLs], Short Portable Mental Status Questionnaire [SPMSQ]) from hospital admission to 30 days after discharge, and the length of hospital stay (LOS). RESULTS: Of the 475 patients screened for eligibility, 281 (171 [60.9%] male, mean [SD] age 74.7 [5.2] years) were enrolled and randomized to receive t-HELP (n = 152) or usual care (n = 129). Postoperative delirium occurred in 4 participants (2.6%) in the intervention group and in 25 (19.4%) in the control group, with a relative risk of 0.14 (95% CI, 0.05-0.38). The number needed to treat to prevent 1 case of POD was 5.9 (95% CI, 4.2-11.1). Participants in the intervention group compared with the control group showed less decline in physical function (median [interquartile range] for ADLs: −5 [−10 to 0] vs −20 [−30 to −10]; P

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.

INTRODUCTION AND OBJECTIVES:Frailty is an important predictor of poor medical and surgical outcomes among older individuals, however, the impact of frailty on second- and third-line treatments for ...

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

Objectives Primary objective: to use advanced nonparametric techniques to determine risk factors for readmission after colorectal cancer surgery in elderly adults. Secondary objective: to compare this methodology with traditional parametric methods. Design Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), nonparametric techniques were used to evaluate the risk of readmission in elderly adults undergoing surgery for colorectal cancer in 2011 and 2012. Setting More than 200 hospitals participating in the NSQIP database. Participants Individuals aged 65 and older who underwent surgery for colorectal cancer in 2011 and 2012 (N = 2,117). Measurements Age-stratified robust nonparametric predictive model (classification and regression tree (CART) analysis) of 30-day readmission for elderly adults undergoing surgery for colorectal cancer. Results Recent chemotherapy was the most important predictor of readmission in participants aged 65 to 74, with 20% of those with recent chemotherapy and 11% of with no recent chemotherapy being readmitted. Participants aged 75 to 84 who had recently undergone chemotherapy had a readmission rate of 23%, whereas those with no chemotherapy had a readmission rate of 9%. Being underweight was the greatest predictor of readmission (30%) in participants aged 85 and older. These methods were found to be more robust than traditional logistic regression. Conclusion Specific age-related preoperative factors help predict readmission in elderly adults undergoing colorectal cancer surgery. Results of the nonparametric CART analysis are better than traditional regression analysis and help physicians to clinically stratify based on age. This model may help identify individuals in whom intervention may be helpful in reducing readmission after surgery.

Background Knowledge about expected recovery after hip fracture is essential to help patients and families set realistic expectations and plan for the future.