Effectiveness of Comanagement Model: Geriatric Medicine and Vascular Surgery.

ABSTRACT

OBJECTIVES: Older surgical patients frequently develop postoperative complications due to their frailty and multiple comorbidities. Geriatric medicine consultation helps to optimize risk factors and improve outcomes in patients with hip fracture. This study aimed to evaluate patient outcomes before and after comanagement model implementation between geriatric medicine (Geriatric Surgical Service) and vascular surgery services. DESIGN: This was a case-control study involving emergency vascular surgical patients who were comanaged by vascular surgery, geriatric medicine, and geriatric nursing services. SETTINGS AND PARTICIPANTS: This study was conducted in a tertiary hospital in Singapore from 2015 to 2018 with acute vascular surgical patients aged older than 65 years. METHODS: A retrospective cohort of 135 patients from 2013 to 2014 (control group) who fulfilled the criteria for the comanagement model was compared with a prospective cohort of 348 patients who were comanaged by a geriatric surgical service from 2015 to 2018, and a further subgroup analysis of patients between 2015 and 2016 (n = 150) (early intervention group) and between 2017 and 2018 (n = 198) (late intervention group) was performed. RESULTS: Comanaged patients had a significantly shorter length of hospital stay (11.6 vs 20.8 days, P = .001), reduced nosocomial infections (3% vs 12% for urinary tract infection, P = .003) and decreased 30-day readmission rates (22% vs 34%, P = .011). A trend of a decreased incidence of fluid overload was noted in patients comanaged with the geriatric surgical service (3% vs 7%, P = .073). Subgroup analysis showed progressive reductions in the length of stay (15.4 vs 11.6 days, P = .001), 30-day readmission rate (35% vs 22%, P = .01), and nosocomial urinary tract infection (8% vs 3%, P = .003) between the early intervention group and the late intervention group. Although they were not statistically significant, reductions were also observed in the delirium rate (13% vs 11%) and other postoperative medical complications in the early intervention group and the late intervention group. CONCLUSION AND IMPLICATIONS Despite having increasing comorbidities, older vascular surgical inpatients had a significantly shorter length of stay, reduced nosocomial infections, and decreased 30-day readmission rates through a comanagement model with vascular surgery and geriatric medicine services. Improvements in outcomes were observed over time as the model of care evolved. Geriatric medicine intervention in the perioperative period improves the outcomes of older acute vascular surgical patients.