Quality of life among older patients after elective ventral hernia repair: A retrospective review.

BACKGROUND: Ventral hernia repair is a common elective general surgery procedure among older patients, a population at greater risk of complications. Prior research has demonstrated improved quality of life in this population despite increased risk of complications. This study sought to assess the relationship between post-ventral hernia repair quality of life and patient frailty. We hypothesized that frail patients would report smaller gains in quality of life compared to the non-frail group. METHODS: The Abdominal Core Health Quality Collaborative was used to identify a cohort of patients 65 years of age or older undergoing elective ventral hernia repair from 2018 to 2022. Patients were categorized based on their modified frailty index scores as not frail/prefrail, frail, and severely frail. Quality of life was assessed using a patient-reported 12-item scale preoperatively, 30 days, 6 months, and 1 year postoperatively. RESULTS: A total of 3,479 patients were included: 30.93% non-frail, 47.17% frail, and 21.90% severely frail. Severely frail patients had lower quality of life scores at baseline (P = .001) but reported higher quality of life at both 30 days (1.24 points higher, 95% confidence interval (-1.51, 2.52), P = .010) and 6 months (0.92 points higher, 95% confidence interval (-2.29, 4.13), P = .005). Severely frail patients had higher rates of surgical site complications (P < .001) but no difference in 30-day readmissions. CONCLUSION: Our results found that frail patients reported the greatest increase in quality of life 1 year from baseline, showing that they, when selected appropriately, can gain equal benefits and have similar surgical outcomes as their non-frail counterparts.

Outcomes and quality of life of frail patients following elective ventral hernia repair: Retrospective review of a national hernia collaborative.

BACKGROUND: Ventral hernia repair (VHR) is one of the most common general surgery procedures among older adults but is often deferred due to a higher risk of complications. This study compares postoperative quality of life (QOL) and complications between frail and non-frail patients undergoing elective VHR. We hypothesized that frail patients would have higher complication rates and smaller gains in quality of life compared to non-frail patients. STUDY DESIGN: Patients 65 years of age and older, undergoing elective VHR between 2018 and 2022 were selected from the ACHQC (Abdominal Core Health Quality Collaborative) and grouped based on frailty scores obtained using the Modified Frailty Index (mFI-5). Logistic regression adjusting for hernia characteristics (size, recurrent, parastomal, incisional) were performed for 30-day outcomes including surgical site infections (SSI), surgical site occurrences (SSO), surgical site infections/occurrences requiring procedural intervention (SSOPI), and readmission. Multivariable analyses controlling for patient and procedure characteristics were performed comparing QOL scores (HerQLes scale, 0-100) at baseline, 30 days, 6 months and 1 year postoperatively. RESULTS: A total of 4888 patients were included, 29.17% non-frail, 47.87% frail, and 22.95% severely frail. On adjusted analysis, severely frail patients had higher odds of SSO (most commonly seroma formation) but no evidence of a difference in SSI, SSOPI, readmission or mortality. Severely frail patients had lower median QOL scores at baseline (48.3/100, IQR 26.1-71.7, p â€‹= â€‹0.001) but reported higher QOL scores at both 30-days (68.3/100, IQR 41.7-88.3, p â€‹= â€‹0.01) and 6-months (86.7/100, IQR 65.0-93.3, p â€‹= â€‹0.005). CONCLUSION: Severely frail patients reported similar increases in QOL and similar complications to their not frail counterparts. Our results demonstrate that appropriately selected older patients, even those who are severely frail, may benefit from elective VHR in the appropriate clinical circumstance.

Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias.

INTRODUCTION: Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown. METHODS: The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups. RESULTS: In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013). CONCLUSIONS: This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.

The effect of frailty and age on outcomes in elective paraesophageal hernia repair.

INTRODUCTION: Paraesophageal hernia repair (PEHR) is a safe and effective operation. Previous studies have described risk factors for poor peri-operative outcomes such as emergent operations or advanced patient age, and pre-operative frailty is a known risk factor in other major surgery. The goal of this retrospective cohort study was to determine if markers of frailty were predictive of poor peri-operative outcomes in elective paraesophageal hernia repair. METHODS: Patients who underwent elective PEHR between 1/2011 and 6/2022 at a single university-based institution were identified. Patient demographics, modified frailty index (mFI), and post-operative outcomes were recorded. A composite peri-operative morbidity outcome indicating the incidence of any of the following: prolonged length of stay (≥ 3 days), increased discharge level of care, and 30-day complications or readmissions was utilized for statistical analysis. Descriptive statistics and logistic regression were used to analyze the data. RESULTS: Of 547 patients who underwent elective PEHR, the mean age was 66.0 ± 12.3, and 77.1% (n = 422) were female. Median length of stay was 1 [IQR 1, 2]. ASA was 3-4 in 65.8% (n = 360) of patients. The composite outcome occurred in 32.4% (n = 177) of patients. On multivariate analysis, increasing age (OR 1.021, p = 0.02), high frailty (OR 2.02, p < 0.01), ASA 3-4 (OR 1.544, p = 0.05), and redo-PEHR (OR 1.72, p = 0.02) were each independently associated with the incidence of the composite outcome. On a regression of age for the composite outcome, a cutoff point of increased risk is identified at age 72 years old (OR 2.25, p < 0.01). CONCLUSION: High frailty and age over 72 years old each independently confer double the odds of a composite morbidity outcome that includes prolonged post-operative stay, peri-operative complications, the need for a higher level of care after elective paraesophageal hernia repair, and 30-day readmission. This provides additional information to counsel patients pre-operatively, as well as a potential opportunity for targeted pre-habilitation.

Frailty in emergency general surgery: Low-risk procedures pose similar risk as high-risk procedures for frail patients.

BACKGROUND: The association of frailty on postoperative outcomes after elective and emergency general surgery procedures has been widely studied. However, this association has not been examined in the geriatric population stratified by emergency general surgery procedural risk. METHODS: A retrospective cohort study was performed using the 2012 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database. We identified geriatric patients (age ≥65 years) undergoing an emergency general surgery procedure within 48 hours of admission stratified by the procedural risk. Frailty was accessed using Modified 5-item Frailty Index, and the patients were divided into 4 groups Modified 5-item Frailty Index = 0, 1, 2, and ≥3. Multivariable logistic regression was used to assess the impact of increasing Modified 5-item Frailty Index score on postoperative complications, failure-to-rescue, and readmissions. RESULTS: In the study, 16,911 low risk procedure emergency general surgery patients were grouped as (33.3%) Modified 5-item Frailty Index = 0, (45.1%) Modified 5-item Frailty Index = 1, (18.7%) Modified 5-item Frailty Index = 2, and (2.9%) Modified 5-item Frailty Index ≥3 respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 2.1 [1.3-3.5], Modified 5-item Frailty Index ≥ 3: 2.2 [1.2-4.2]), failure-to-rescue (Modified 5-item Frailty Index = 2: 2.3 [1.3-4.0], Modified 5-item Frailty Index ≥ 3: 2.3 [1.2-4.6]), readmission (Modified 5-item Frailty Index = 2: 1.4 [1.2-1.7], Modified 5-item Frailty Index ≥ 3: 1.5 [1.1-2.1]). In addition, 30,305 high-risk patients undergoing procedure emergency general surgery were grouped as (24.1%) Modified 5-item Frailty Index = 0, (44.9%) Modified 5-item Frailty Index = 1, (24.0%) Modified 5-item Frailty Index = 2, and (7.0%) Modified 5-item Frailty Index ≥3, respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 1.2 [1.2-1.3], Modified 5-item Frailty Index ≥3: 1.7 [1.5-2.0]), failure-to-rescue (Modified 5-item Frailty Index = 2: 1.3 [1.2-1.5], Modified 5-item Frailty Index ≥3: 1.5 [1.3-1.7]), readmission (Modified 5-item Frailty Index = 2: 1.3 [1.2-1.4], Modified 5-item Frailty Index ≥3: 1.6 [1.4-1.9]). CONCLUSION: Increasing levels of frailty in geriatric emergency general surgery patients are associated with higher levels of postoperative complications, failure-to-rescue, and readmission. Clinicians should consider frailty in assessing the risk of even low-risk surgeries in this population.

Barriers to and recommendations for integrating the age-friendly 4-Ms framework into electronic health records.

BACKGROUND: The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms. METHODS: Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media. RESULTS: Sixty-six respondents from all geographic segments of the U.S. (n = 62) and non-U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts. CONCLUSIONS: The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.

Robotic vs. Open Approach for Older Adults Undergoing Retromuscular Ventral Hernia Repair.

OBJECTIVE: To describe 30-day outcomes including post-operative complications, readmissions, and quality of life score changes for older adults undergoing elective ventral hernia repair with retromuscular mesh placement and to compare rates of these outcomes for individuals undergoing robotic versus open approaches. SUMMARY OF BACKGROUND DATA: Over one third of patients presenting for elective ventral hernia repair are over the age of 65 and many have complex surgical histories that warrant intricate hernia repairs. Robotic ventral hernia repairs have gained increasing popularity in the US and in some studies have demonstrated decreased rates of postoperative complications, and less pain resulting in shorter hospital stays. However, the robotic approach has several downsides including prolonged operative times as well as the use of pneumo-peritoneum which may be risky in older patients. METHODS: We performed a retrospective review of prospectively collected data in a national hernia specific registry (the Abdominal Core Health Quality Collaborative) and identified patients over the age of 65 undergoing either an open or robotic retromuscular ventral hernia repair. After propensity score matching adjusting for demographic, clinical, and hernia related factors, logistic regression was used to compare 30-day complications, readmission, and quality of life (QoL) scores as captured by the HerQLes scale for patients undergoing each approach. RESULTS: Of 2128 patients who met inclusion criteria, 1695 (79.7%) underwent open ventral hernia repair while 433 (20.3%) underwent robotic repair. After propensity score matching, there were 350 robotic cases and 759 open cases for analysis. Patients undergoing robotic repairs demonstrated significantly shorter length of stays (1 vs 4 days, P < 0.01) and had equivalent odds of both 30-day post-operative complications (odds ratio [OR] 1.15 95% confidence interval 0.92-1.44) and readmission (OR 1.09 95% confidence interval 0.74-1.6) compared to the open approach. QoL scores were similar between groups at 30 days but were slightly better for robotic patients at 1 year (92 vs 84 P < 0.01). CONCLUSIONS: Robotic ventral hernia repair is an option for appropriately selected older patients undergoing retromuscular ventral hernia repair, demonstrating shorter hospital stays and equivalent rates of complications and readmissions in the post-operative period. However, more data is needed regarding QoL outcomes and long-term function, especially as it relates to recurrence rates, between the two approaches.

Community distress as a predictor of early hernia recurrence for older adults undergoing ventral hernia repair (VHR).

BACKGROUND: Social cohesion and neighborhood support have been linked to improved health in a variety of fields, but is not well-studied among the elderly population. This is particularly evident in surgical populations. Therefore, this study sought to assess the potential role of community distress in predicting early hernia recurrence among older adults. METHODS: The Abdominal Core Health Quality Collaborative (ACHQC) was used to identify patients aged 65 or older undergoing elective ventral hernia repair with zip code data available. Patients were linked to the Distressed Communities Index (DCI), which is a national database that assigns a score of 0-100 to each zip code based on 7 measures of neighborhood prosperity. Quintiles were used to compare groups: prosperous (0-20), comfortable (21-40), mid-tier (41-60), at-risk (61-80), and distressed (81-100). Distressed (0-20), at-risk (21-40), mid-tier (41-60), comfortable (61-80), and prosperous (81-100). Time to recurrence for neighborhood distress quintiles was examined using a Cox proportional hazards model. RESULTS: In total, 9819 patients were included in the study, including 3056 (31.1%) prosperous, 2307 (23.5%) comfortable, 1795 (18.2%) mid-tier, 1390 (14.2%) at-risk, and 1271 (12.9%) distressed. Distressed communities had lower mean age and greater proportion of racial minorities (p < 0.001). Open repairs were significantly more common among the distressed group (66.7%), as were all comorbidities (p < 0.001). Recurrence-free survival was shorter for distressed communities compared to prosperous after adjusting for baseline characteristics (HR 1.3, 95% CI 1.07-1.67, p = 0.01). Mean time to recurrence was lowest for patients living in distressed communities, indicating the worst recurrence rates, while mean time to recurrence was greatest for those in prosperous zip codes (p < 0.001). CONCLUSION: Older VHR patients presenting from distressed zip codes, as identified by the Distressed Communities Index, experience hernia recurrence significantly sooner as compared to patients from prosperous zip codes. This study may provide evidence of the role of neighborhood and environmental factors in caring for older patients following VHR.

Scaling and spreading the electronic capture of patient-reported outcomes using a national surgical quality improvement programme: a feasibility study protocol.

INTRODUCTION: Patient-reported outcomes (PROs) are important for research, patient care and quality assessment; however, large-scale collection among the US surgical patient population has been limited. A structured implementation and dissemination programme focused on electronic PRO collection could improve the use of PROs data to improve surgical care. This study aims to (1) evaluate the feasibility of PRO collection among a larger volume of surgical patients through the stepwise implementation of PRO collection processes in a sample of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hospitals; (2) identify best practices and barriers to PRO collection through qualitative study of participating hospitals and patients; and (3) evaluate the utility of PROs at detecting differences in the quality of care among surgical patients. METHODS AND ANALYSIS: ACS NSQIP-participating hospitals are being recruited, and patients at participating hospitals who undergo elective surgical procedures receive invitations via e-mail or short message service 'text'message to complete PROs after surgery. Validated PRO measures which evaluate physical and mental health-related quality of life, pain, fatigue, physical function and shared decision-making were selected. The scalability of PRO collection will be assessed by site enrolment, patient accrual and response rates. Qualitative interviews and focus groups will be performed with patients and hospital personnel to identify best practices and barriers to successful enrolment and PRO collection. Multivariable hierarchical regression models will be used to evaluate the distinctness of PROs from clinical outcomes captured in ACS NSQIP and the ability of PROs to detect differences in hospital performance. ETHICS AND DISSEMINATION: This study was reviewed by the Advarra Institutional Review Board (IRB) and deemed to be exempt from IRB oversight. Findings will be disseminated through peer-reviewed manuscripts, reports and presentations.

A Quiet Unstable Sitting Test to quantify core stability in clinical settings: Application to adults with ventral hernia.

BACKGROUND: The abdominal core is comprised of the diaphragm, abdominal wall, and pelvic floor, and serves several important functions for balance, movement, and strength. Injury to this area, such as hernia, can have substantial impact. The Quiet Unstable Sitting Test involves individuals seated on the rounded surface of a BOSU® balance trainer placed on top of a force plate and situated on a flat, elevated surface. METHODS: An ordinal Quiet Unstable Sitting Test core stability score was calculated from center of pressure measurements, with 0 representing "normal" and < 0 indicating worsening stability. Hernia-Related Quality of Life survey summary scores were assessed (higher scores indicating better quality). FINDINGS: A developmental cohort of 32 was used to establish reliability and normative values for the Quiet Unstable Sitting Test. A control group of 32 participants (43.7 ± 16.2 yrs., BMI 29.0 ± 4.9, 66% Female) was then compared to 21 patients with hernia (56.2 ± 12.5 yrs., BMI 29.2 ± 6.3, 24% Female). Hernia patients had median composite score of -2 and median quality of life score of 66, versus median Quiet Unstable Sitting Test of -0.5 and median quality of life of 93 for controls (p ≤ 0.01). Quality of life and Quiet Unstable Sitting Test scores were not correlated (p > 0.05). INTERPRETATION: Hernia patients demonstrated significantly worse core stability and quality of life. These assessments were independent of one another across the entire population, indicating each measure's unique constructs of patient function. Core stability can be reliably measured in a clinical setting and may help with patient activation and rehabilitation.

A personalized approach empowering successful aging: Patient perspective on fall prevention education.

BACKGROUND: Falls are the leading cause of fatal injury, and the most common cause of nonfatal trauma, among older adults. However, patient perspectives on preferences for obtaining fall education are not well reported. OBJECTIVE: To identify components of successful fall prevention education. DESIGN: Prospective qualitative study. SETTING: Tertiary care center; institutional. PARTICIPANTS: Adults aged 65 years or older with a history of falls who received services from inpatient trauma or outpatient geriatric services. INTERVENTIONS: One-hour face-to-face semistructured interview. MAIN OUTCOME MEASURE: Semistructured interviews sought to determine participants' history of fall education and perceived strengths and weaknesses of various formats of fall education. RESULTS: Nearly all participants (9/10) indicated they had not received fall prevention education of any kind. Many participants (6/10) reported that, despite not receiving any formal education about falls, they had either given or received information about falls from other older adults in their communities. Participants indicated that framing fall education as a part of healthy aging would be more desirable and mentioned involving participants' families as part of the education. The majority of participants (7/10) suggested fall education be delivered through in-person discussion with providers, and most (9/10) indicated this would provide a personalized approach with opportunity for questions. Participants specified fall education should consist of both environmental modifications (5/10) and awareness of one's surroundings (4/10). CONCLUSIONS: Despite histories of falls, nearly all participants reported they had not received formal fall education. However, many indicated they received fall information informally through their communities. Participants agreed successful fall prevention education would be delivered in an empowering way by a trusted member of the care team.

Elective ventral hernia repair provides significant abdominal wall quality of life improvements in older patients.

BACKGROUND: An increasing proportion of ventral hernia patients are over age 65. These patients are frequently offered watchful waiting rather than surgical intervention due to their frail state or perioperative risk. However, many in this age group suffer from significant quality of life impacts that are not well understood. METHODS: We performed a retrospective cohort study using data from the Abdominal Core Health Quality Collaborative (ACHQC), including adults undergoing elective ventral hernia repair from 2013 to 2019. Median differences in Hernia-Related Quality of Life Survey (HerQLes) summary scores at baseline, 30-days, 6-months, and 1 year post operatively were compared in four age categories (18-40, 40-64, 65-75, 76 +) using multivariable regression. Secondary outcomes included major post-operative complications and mortality. RESULTS: Of 6681 patients meeting inclusion criteria, 13.5% were 18-40, 55.8% were 41-64, 25.2% were 65-75, and 5% were 76 + . Patients in the 65-75 age group and those over 76 had higher mean baseline HerQLes scores (51.7 and 60.8) compared to those in the 18-40 and 41-64 groups (45 and 43.3, p < 0.01). Patients 65-75 had smaller increases in HerQLes scores at 30 days (6.7) compared to patients in the younger age groups (11.7 for 18-40; 8.3 for 41-64) and the oldest age group (8.3, p < 0.01). However, patients in the older age groups had higher overall median 1 year HerQles Scores (66.7 for 65-75; 78.3 for 76 +) compared to patients in the 18-40 and 41-64 age groups (65 and 58.3, p < 0.01). On multivariable analysis, HerQLes scores at 30 days post-surgery were decreased for patients in the 41-64 (-3.14, CE -5.89, -0.04, p = 0.03) and 65-75 (-4.53; CE -7.65, -1.41, p < 0.01) groups compared to the youngest age group, while those over 76 had no effect. CONCLUSION: Older adults undergoing ventral hernia repair demonstrate equal gains in hernia-related quality of life compared to younger patients and actually report higher quality of life scores at 30 days, 6 months and, 1 year post-surgery.

Greatest Quality of Life Improvement in Patients With Large Ventral Hernias: An Individual Assessment of Items in the HerQLes Survey.

BACKGROUND: Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated. METHODS: Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients. RESULTS: In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P = 0.31). Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P < 0.0001). This held true with subgroup analysis of small (<2 cm), medium (2-6 cm), and large (>6 cm) hernias (P < 0.0001), though a larger improvement was seen in 8 of 12 components in hernias >6 cm (P < 0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P = 0.02). CONCLUSIONS: VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Increasing Frailty in Geriatric Emergency General Surgery: A Cause for Concern.

BACKGROUND: Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. MATERIALS AND METHODS: A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5 = 0, mFI-5 = 1, mFI-5 = 2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. RESULTS: A total of 47,216 patients were included: 27.4% with mFI-5 = 0, 45% with mFI-5 = 1, 22.1% with mFI-5 = 2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5 = 1: odds ratio (OR) 1.48, p=0.003; mFI-5 = 2: OR 2.66, p <0.001; mFI-5 ≥ 3: OR 3.97, p <0.001), 30-day complications (mFI-5 = 1: OR 1.46, p <0.001; mFI-5 = 2: OR 2.48, p <0.001; mFI-5≥3: OR 5.01, p <0.001), reoperation (mFI-5 = 1: OR 1.42, p = 0.020; mFI-5 = 2: OR 1.70, p = 0.021; mFI-5 ≥ 3: OR 2.18, p = 0.009) and all-cause mortality (mFI-5 = 1: OR 1.49, p=0.001; mFI-5 = 2: OR 2.67, p <0.001; mFI-5 ≥ 3: 3.96, p <0.001). CONCLUSIONS: Increasing frailty in geriatric EGS patients is associated with significantly higher rates of FTR, 30-day complications, reoperations, and all-cause mortality. The mFI-5 score can be used to assess frailty and better anticipate the postoperative course of vulnerable geriatric patients.

Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen.

BACKGROUND: Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans. METHODS: Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. RESULTS: We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). CONCLUSIONS: Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.

The Rose-Colored Glasses of Geriatric Fall Patients: Inconsistencies Between Knowledge of Risk Factors for and Actual Causes of Falls.

BACKGROUND: Falls are the leading cause of fatal injury, and most common cause of non-fatal trauma, among older adults. We sought to elicit older patient's perspectives on fall risks for the general population as well as contributions to any personal falls to identify opportunities to improve fall education. METHODS: Ten patients with a history of falls from inpatient trauma and outpatient geriatric services were interviewed. Transcripts were analyzed independently by five individuals using triangulation and constant comparison (NVivo11, QSR International) to compare fall risks to fall causes. RESULTS: All patients reported that either they (9/10 participants) or someone they knew (8/10) had fallen. Despite this, only two personally worried about falling. Patient perceptions of fall risks fell into seven major themes: physiologic decline (8/10); underestimating limitations (7/10); environmental hazards (7/10), lack of awareness/rushing (4/10), misuse/lack of walking aids (3/10); positional transitions (2/10), and improper footwear (1/10). In contrast, the most commonly reported causes of personal falls were lack of awareness/rushing (7/10), environmental hazards (3/10), misuse/lack of walking aids (2/10), improper footwear (2/10), physiologic decline (2/10), underestimating limitations (1/10) and positional transitions (1/10). In general tended to attribute their own falls to their surroundings and were less likely to attribute physical or psychological limitations. CONCLUSION: Despite participants identifying falls as a serious problem, they were unlikely to worry about falling themselves. Participants were able to identify common fall risks. However, when speaking about personal experience, they were more likely to blame environmental hazards or rushing, and minimized the role of physiologic decline and personal limitations.

The association between self-declared acute care surgery services and critical care resources: Results from a national survey.

PURPOSE: We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. METHODS: 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. RESULTS: 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. CONCLUSIONS: Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.