Implementation of a Multidisciplinary Team to Improve the Quality of Care for Older Surgical Patients at a Rural Academic Medical Center.

For the first time in history, people age older than 65 years make up >20% of the non-metro population, compared with 16% of the metro population. From 2010 to 2020 the nonmetro population age older than 65 years grew by 22%, while the working-age population declined by 4.9%, and the population aged under 18 years declined by 5.7%.1,2 Multidisciplinary geriatric surgical programs are an increasingly recognized approach to the care of older surgical patients and preliminary data suggest they can reduce length of stay. Although rural areas have the greatest proportion of patients age older than 65 years, implementation of such programs faces special challenges in rural settings with limited resources. Dartmouth-Hitchcock Medical Center is one of the most rural academic centers in the United States. Challenges include a shortage of geriatric-trained providers, long distances to access primary care and subspecialists, and extremely limited postacute care options and skilled nursing facility beds. To address the unique needs of our provider and patient population we began with a development period where we conducted stakeholder interviews. Using these data, we mapped out a workflow and developed pilot projects to address different portions of the workflow, such as preoperative screening for frailty and cognitive impairment, interdisciplinary weekly case conferences, proactive case management, delirium and geriatric surgery postoperative pathway order sets, and a variety of tools for reorientation and delirium management. Herein we describe the process of development and pragmatic clinical implementation of geriatric-focused care for older surgical patients in our rural tertiary center, including some of the main challenges we faced and the strategies we undertook to overcome them, and some of our early patient centered and clinical outcomes. This information may assist other institutions as they design geriatric-focused surgical programs to address the growing population of older adults and the need for compliance with state legislation. The clinical program described is not a research study, and the outcome data we report is for the purpose of description, and should not be interpreted as a rigorous research investigation of the effect of our intervention.

Association of neurocognitive disorders with morbidity and mortality in older adults undergoing major surgery in the USA: a retrospective, population-based, cohort study.

BACKGROUND: Neurocognitive disorders become increasingly common as patients age, and increasing numbers of surgical interventions are done on older patients. The aim of this study was to understand the clinical characteristics and outcomes of surgical patients with neurocognitive disorders in the USA in order to guide future targeted interventions for better care. METHODS: This retrospective cohort study used claims data for US Medicare beneficiaries aged 65 years and older with a record of inpatient admission for a major diagnostic or therapeutic surgical procedure between Jan 1, 2017, and Dec 31, 2018. Data were retrieved through a data use agreement between Dartmouth Hitchcock Medical Center and US Centers for Medicare and Medicaid Services via the Research Data Assistance Center. The exposure of interest was the presence of a pre-existing neurocognitive disorder as defined by diagnostic code within 3 years of index hospital admission. The primary outcome was mortality at 30 days, 90 days, and 365 days from date of surgery among all patients with available data. FINDINGS: Among 5 263 264 Medicare patients who underwent a major surgical procedure, 767 830 (14·59%) had a pre-existing neurocognitive disorder and 4 495 434 (85·41%) had no pre-existing neurocognitive disorder. Adjusting for demographic factors and comorbidities, patients with a neurocognitive disorder had higher 30-day (hazard ratio 1·24 [95% CI 1·23-1·25]; p<0·0001), 90-day (1·25 [1·24-1·26]; p<0·0001), and 365-day mortality (1·25 [1·25-1·26]; p<0·0001) compared with patients without a neurocognitive disorder. INTERPRETATION: Our findings suggest that the presence of a neurocognitive disorder is independently associated with an increased risk of mortality. Identification of a neurocognitive disorder before surgery can help clinicians to better disclose risks and plan for patient care after hospital discharge. FUNDING: Department of Anesthesiology and Perioperative Medicine at Dartmouth Hitchcock Medical Center.