Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

OBJECTIVE: The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. BACKGROUND: Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. METHODS: Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. RESULTS: The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. CONCLUSIONS: This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway.

OBJECTIVE: To examine geriatric-specific outcomes following implementation of a multispecialty geriatric surgical pathway (GSP). BACKGROUND: In 2018, we implemented a GSP in accordance with the proposed 32 standards of American College of Surgeons' Geriatric Surgery Verification Program. METHODS: This observational study combined data from the electronic health record system (EHR) and ACS-National Surgery Quality Improvement Program (NSQIP) to identify patients ≥65 years undergoing inpatient procedures from 2016 to 2020. GSP patients (2018-2020) were identified by preoperative high-risk screening. Frailty was measured with the modified frailty index. Surgical procedures were ranked according to the operative stress score (1-5). Loss of independence (LOI), length of stay, major complications (CD II-IV), and 30-day all-cause unplanned readmissions were measured in the pre/postpatient populations and by propensity score matching of patients by operative procedure and frailty. RESULTS: A total of 533 (300 pre-GSP, 233 GSP) patients similar by demographics (age and race) and clinical profile (frailty) were included. On multivariable analysis, GSP patients showed decreased risk for LOI [odds ratio (OR) 0.26 (0.23, 0.29) P <0.001] and major complications [OR: 0.63 (0.50, 0.78) P <0.001]. Propensity matching demonstrated similar findings. Examining frail patients alone, GSP showed decreased risk for LOI [OR: 0.30 (0.25, 0.37) P <0.001], major complications [OR: 0.31 (0.24, 0.40) P <0.001], and was independently associated with a reduction in length of stay [incidence rate ratios: 0.97 (0.96, 0.98), P <0.001]. CONCLUSIONS: In our diverse patient population, implementation of a GSP led to improved geriatric-specific surgical outcomes. Future studies to examine pathway compliance would promote the identification of further interventions.

Complications of Corticosteroid Therapy: A Comprehensive Literature Review.

Relevance to Patient Care and Clinical Practice: Corticosteroids are among the most prescribed medications, particularly during the COVID-19 era. The literature has clearly highlighted the dangers of prolonged, high-dose corticosteroid use, which is important for clinicians to consider before treating patients in their clinical practices. Objective: The objective of this article is to review the literature on complications of corticosteroid use, review corticosteroid pharmacokinetics, and provide an updated reference on risks associated with corticosteroid therapy, especially at higher doses. Data Sources: A conventional literature search of PubMed was conducted without restrictions on publication date. Search terms included "corticosteroids," "avascular necrosis," "gastrointestinal bleeding," and "complications." Study Selection and Data Extraction: Pertinent systematic review/meta-analyses and randomized controlled trials were reviewed for study inclusion. Data Synthesis: Corticosteroids were associated with complications including avascular necrosis, gastrointestinal bleeding, myocardial infarction, heart failure, cerebrovascular events, diabetes mellitus, psychiatric syndromes, ophthalmic complications, tuberculosis reactivation, and bacterial sepsis. Increased daily and cumulative doses were associated with increased excess risk of complications. Cumulative doses greater than 430 mg prednisone equivalent were shown to increase the excess risk of avascular necrosis, with progressively higher rates with higher doses. Risk of gastrointestinal bleeding was significantly increased with corticosteroid usage in the in-patient but not out-patient setting. Conclusion: Since corticosteroids have been associated with the aforementioned severe complications and frequent medicolegal malpractice claims, counseling and informed consent should be performed when prescribing moderate-high dosages of corticosteroids. Further research is needed to characterize the long-term effects of corticosteroid usage in COVID-19 patients.

Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature.

OBJECTIVE: To review the literature on corticosteroid use and provide recommendations on patient counseling and/or consent to promote judicious prescribing and reduce the incidence of corticosteroid-related lawsuits. METHOD: A conventional literature search of PubMed on corticosteroid-related medicolegal cases was undertaken. Search terms included "medicolegal," "otolaryngology," and "adrenocorticosteroids." A medical subjects headings search with the keywords "adrenal cortex hormones" and "jurisprudence" was also performed. RESULTS: Corticosteroids have been reported as the third most frequent medication involved in malpractice claims, oftentimes leading to disproportionately costly payments. The most common specialties found to be involved in corticosteroid related medicolegal cases included dermatology (12%), primary care (10%), and neurologists or neurosurgeons (6%). The most common complications encountered were avascular necrosis (39%), changes in mood (16%), infection (14%), and vision changes (14%). Only a few cases corticosteroid-related litigation regarding otolaryngologists were identified. More frequent causes for otolaryngology claims were intraoperative complications, deficits in diagnoses, and failures or delays in treatment. Three medicolegal pitfalls regarding corticosteroid use were identified from this review included: (1) insufficient advising, (2) lack of or incomplete informed consent, and (3) the significance of the patient-physician relationship. CONCLUSION: Despite the scarcity of corticosteroid-related medicolegal literature pertaining to otolaryngologists, corticosteroids are one of the most widely prescribed medications in the field of otolaryngology and have been shown to have a high rate of medical malpractice claims in medicine. Counseling and consenting the patient, as well as developing a strong physician-patient relationship, are integral processes in addressing any adverse effects occurring during therapy, and may also help to decrease the incidence and success of litigation against otolaryngologists.

Does age increase perioperative complications for single-stage bilateral total hip arthroplasty?

The potential of post-operative complication may exclude elderly patients from undergoing single-staged bilateral total hip arthroplasty (SSBTHA). This study retrospective compared perioperative complications between SSBTHA patients <70 (N = 157) and ≥70 (N = 56) years of age. Patients ≥70 had significantly lower body mass index (p = 0.029) and had a higher ASA classification (p = 0.041) compared to patients <70. No differences in post-operative complications or transfusion rates were found between age groups. However, patients ≥70 were less likely to be discharged home. While SSBTHA can safely be performed in patients ≥70, the risk of transfusion may suggest pre-operative hemoglobin screenings, especially for patients ≥70.

Utilization of Silicone Sheet as a Protective Guide During Transoral Robotic Tongue Base Surgery.

This article presents a simple technique where a silicone sheet is used during transoral robotic surgery (TORS) to protect the upper airway structures from thermal damage during a base of tongue procedure. We review 10 cases of TORS tongue base reduction with the use of this technique, with no complications and with reduction of thermal damage to the lingual epiglottis and surrounding pharyngeal wall. Furthermore, it served as a guide during tongue base dissection to provide visual and tactile feedback to the inferior limit of resection, as well as to protect the endotracheal tube. The silicone sheet is an ideal material for use as a thermal barrier due to its widespread availability, intrinsic thermal properties, and translucency. The technique of using the silicone sheet is easy to implement and may prove useful to many transoral robotic surgeons, especially for newly trained TORS users and trainees.

Preoperative Frailty Assessment, Operative Severity Score, and Early Postoperative Loss of Independence in Surgical Patients Age 65 Years or Older.

BACKGROUND: Preoperative discussions around postoperative discharge planning have been amplified by the COVID pandemic. We wished to determine whether our preoperative frailty screen would predict postoperative loss of independence (LOI). STUDY DESIGN: This single-institutional study included demographic, procedural, and outcomes data from patients 65 years or older who underwent frailty screening before a surgical procedure. Frailty was assessed using the Edmonton Frail Scale. The Operative Severity Score was used to categorize procedures. The Hierarchical Condition Category risk-adjustment score, as calculated by the Centers for Medicare and Medicaid Services, was included. LOI was defined as an increase in support outside of the home after discharge. Univariable, multivariable logistic regressions, and adjusted postestimation analyses for predictive probabilities of best fit were performed. RESULTS: Five hundred and thirty-five patients met inclusion criteria and LOI was seen in 38 patients (7%). Patients with LOI were older, had a lower BMI, a higher Edmonton Frail Scale score (7 vs 3.0; p < 0.001), and a higher Hierarchical Condition Category score than patients without LOI. Being frail and undergoing a procedure with an Operative Severity Score of 3 or higher was independently associated with an increased risk of LOI. In addition, social dependency, depression, and limited mobility were associated with an increased risk for LOI. On multivariable modeling, frailty status, undergoing an operation with an Operative Severity Score of 3 or higher, and having a Hierarchical Condition Category score ≥1 were the most predictive of LOI (odds ratio 12.72; 95% CI, 12.04 to 13.44; p < 0.001). In addition, self-reported depression, weight loss, and limited mobility were associated with a nearly 11-fold increased risk of postoperative LOI. CONCLUSIONS: This study was novel, as it identified clear, generalizable risk factors for LOI. In addition, our findings support the implementation of preoperative assessments to aid in care coordination and provide specific targets for intervention.