"There's So Much That They're Enduring": Experiences of Older Adults Undergoing Major Elective Surgery.

OBJECTIVE: This qualitative study aimed to explore the psychosocial experience of older adults undergoing major elective surgery from the perspective of both the patient and family caregiver. SUMMARY BACKGROUND DATA: Older adults face unique psychological and social vulnerabilities that can increase susceptibility to poor health outcomes. How these vulnerabilities influence surgical treatment and recovery is understudied in the geriatric surgical population. METHODS: Adults aged 65 and older undergoing a high-risk major elective surgery at the University of California, San Francisco and their caregivers were recruited. Semi-structured interviews were conducted at three time points: 1-2 weeks before surgery, and at 1- and 3-months following surgery. An inductive qualitative approach was used to identify underlying themes. RESULTS: Twenty-five older adult patients (age range 65-82 years, 60% male) and 11 caregivers (age range 53-78 years, 82% female) participated. Three themes were identified. First, older surgical patients experienced significant challenges to emotional well-being both before and after surgery, which had a negative impact on recovery. Second, older adults relied on a combination of personal and social resources to navigate these challenges. Lastly, both patients and caregivers desired more resources from the healthcare system to address "the emotional piece" of surgical treatment and recovery. CONCLUSIONS: Older adults and their caregivers described multiple overlapping challenges to emotional well-being that spanned the course of the perioperative period. Our findings highlight a critical component of perioperative care with significant implications for the recovery of older surgical patients.

Public Opinions About Surgery in Older Adults: A Thematic Analysis.

OBJECTIVE: To examine public opinions of surgery in older adults. BACKGROUND: Increasing numbers of older adults are undergoing surgery. National healthcare organizations recognize the increased risks of postoperative complications and mortality in the older surgical population and have made efforts to improve the care of older adults undergoing surgery through hospital-level programs. However, limited research has explored the opinions and responses of the wider U.S. public regarding surgery in older adults. METHODS: We performed a qualitative, thematic analysis of reader comments posted in response to online newspaper articles relating to surgery in older adults. Articles were published in 2019-2020 and targeted for a popular press audience. RESULTS: Nine hundred eight reader comments posted in response to 6 articles relating to surgery in older adults were identified. Articles were published in online editions of print newspapers with a digital circulation between 1.3 and 5.7 million subscribers. Three themes were identified: (1) wariness/distrust towards healthcare: including general distrust of medicine and distrust of surgery, (2) problems experienced: ineffective communication and unrealistic expectations, and (3) recommended solutions: the need for multidisciplinary teams and patient-centered communication. CONCLUSIONS: Overall, the public viewed surgery in older adults with wariness/distrust due to ineffective communication and unrealistic expectations. Specialized surgical care tailored to the unique needs of older adults is needed. The public perspective suggests that U.S. health systems should strongly consider adopting programs that provide care to meet the unique needs of older adults undergoing surgery and ultimately improve both patient outcomes and their surgical experience.

Advance Care Planning Prior to Death in Older Adults with Hip Fracture.

BACKGROUND: Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown. OBJECTIVE: To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP. DESIGN: Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data. PARTICIPANTS: Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey. MAIN MEASURES: Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP. KEY RESULTS: Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06-0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35-0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26-0.72). No clinical factors were found to be associated with ACP completion prior to death. CONCLUSIONS: A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP.

Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report From the Coalition for Quality in Geriatric Surgery.

OBJECTIVE: The aim of this study was to establish high-quality, valid standards to improve surgical care of the older adult. BACKGROUND: The aging population increases demand for high-quality surgical care. Building upon prior guidelines, quality indicators, and pilot projects, the Coalition for Quality in Geriatric Surgery (CQGS) includes 58 diverse stakeholder organizations committed to improving geriatric surgery. METHODS: Using a modified RAND-UCLA Appropriateness Methodology, 44 of 58 CQGS Stakeholders twice rated validity (primary outcome) and feasibility for 308 standards, ranging from goals and decision-making, pre-operative assessment and optimization, perioperative and postoperative care, to transitions of care beyond the acute care hospital. RESULTS: Three hundred six of 308 (99%) standards were rated as valid to improve quality of geriatric surgery. There were 4 sections. Section 1 included 157 (57%) standards and focused on goals and decision-making, preoperative optimization, and transitions into and out of the hospital. Section 2 included 84 (27.3%) standards focused on in-hospital care, across the immediate preoperative, intraoperative, and postoperative phases. Section 3 included 59 (19.1%) standards about program management, including personnel and committee structure, credentialing, and education. Section 4 included 8 (2.6%) standards establishing overarching concepts for data collection and patient follow-up. Two hundred ninety of 308 standards (94.2%) were rated as feasible; 18 (5.8%) were rated as uncertain in feasibility. CONCLUSIONS: CQGS Stakeholders rated the vast majority of standards of care as highly valid (99%) and feasible (94%) for improving the quality of surgical care provided to older adults. Future work will focus on a pilot phase to better understand and address challenges to implementation of the standards.

Rates of Recovery to Pre-Fracture Function in Older Persons with Hip Fracture: an Observational Study.

BACKGROUND: Knowledge about expected recovery after hip fracture is essential to help patients and families set realistic expectations and plan for the future. OBJECTIVES: To determine rates of functional recovery in older adults who sustained a hip fracture based on one's previous function. DESIGN: Observational study. PARTICIPANTS: We identified subjects who sustained a hip fracture while enrolled in the nationally representative Health and Retirement Study (HRS) using linked Medicare claims. HRS interviews subjects every 2 years. Using information from interviews collected during the interview preceding the fracture and the first interview 6 or more months after the fracture, we determined the proportion of subjects who returned to pre-fracture function. MAIN MEASURES: Functional outcomes of interest were: (1) ADL dependency, (2) mobility, and (3) stair-climbing ability. We examined baseline characteristics associated with a return to: (1) ADL independence, (2) walking one block, and (3) climbing a flight of stairs. KEY RESULTS: A total of 733 HRS subjects ≥65 years of age sustained a hip fracture (mean age 84 ± 7 years, 77 % female). Thirty-one percent returned to pre-fracture ADL function, 34 % to pre-fracture mobility function, and 41 % to pre-fracture climbing function. Among those who were ADL independent prior to fracture, 36 % returned to independence, 27 % survived but needed ADL assistance, and 37 % died. Return to ADL independence was less likely for those ≥85 years old (26 % vs. 44 %), with dementia (8 % vs. 39 %), and with a Charlson comorbidity score >2 (23 % vs. 44 %). Results were similar for those able to walk a block and for those able to climb a flight of stairs prior to fracture. CONCLUSIONS: Recovery rates are low, even among those with higher levels of pre-fracture functional status, and are worse for patients who are older, cognitively impaired, and who have multiple comorbidities.

Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative.

BACKGROUND: The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN: The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS: Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS: This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.

Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery.

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.

Anxious, Depressed, and Planning for the Future: Advance Care Planning in Diverse Older Adults.

OBJECTIVES: To determine whether depression and anxiety are associated with advance care planning (ACP) engagement or values concerning future medical care. DESIGN: Cross-sectional. PARTICIPANTS: English- and Spanish-speaking patients, aged 55 years and older, from a San Francisco, CA, county hospital. MEASURES: Depression was measured by the Patient Health Questionnaire 8-item scale, and anxiety was measured by the Generalized Anxiety Disorder 7-item scale, using standardized cutoffs of 10 or more for moderate-to-severe symptoms. ACP engagement was measured using validated surveys of ACP behavior change (e.g., self-efficacy and readiness; mean five-point Likert score) and ACP actions (e.g., ask, discuss, and document wishes; 0- to 25-point scale), with higher scores representing higher engagement. In addition, we asked a question about valuing life extension ("some health situations would make life not worth living"). We used adjusted linear and logistic regression. RESULTS: Mean age of 986 participants was 63 years, 81% were non-White, 39% had limited health literacy, 45% were Spanish speaking, 13% had depression, and 10% had anxiety. After adjustment for demographic and health status variables, participants who were depressed versus not depressed had higher ACP behavior change scores (0.2 points; 95% confidence interval (CI) = 0.06-0.38; P = .007), higher ACP action scores (1.5 points; 95% CI = 0.51-2.57; P = .003), and higher odds of not valuing life extension (odds ratio (OR) = 2.5; 95% CI = 1.5-4.3; P < .001). Results were similar in participants with versus without anxiety (ACP behavior change: 0.2 points; 95% CI = 0.05-0.40; P = .01; ACP action scores: 1.2 points; 95% CI = 0.14-2.32; P = .028; odds of not valuing life extension: OR = 2.3; 95% CI = 1.3-3.9; P = .004). CONCLUSION: Depression and anxiety were associated with greater ACP engagement and not valuing life extension. Although the direction of association between ACP engagement and values with anxiety and depression cannot be determined in this cross-sectional study, these conditions may influence ACP preferences. Future studies should assess whether changes in anxiety or depression affect ACP preferences over time.

Preoperative Depressive Symptoms Associated with Poor Functional Recovery after Surgery.

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.

What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery.

OBJECTIVES: Valued life activities are those activities an individual deems particularly important or meaningful. Surgery in older adults can affect their ability to perform valued activities, but data are lacking. We characterized these activities and assessed performance of them following surgery. DESIGN: Retrospective observational study. SETTING: Preoperative program for older adults undergoing elective surgery at an academic hospital. PARTICIPANTS: Older adults (N = 194) in the program from February 2015 to February 2018. MEASUREMENTS: A preoperative written questionnaire asked, "What are the activities that are most important to you to be able to do when you return home from surgery?" Participants could list up to three activities. Content analysis was used to develop domains of valued life activities and categorize responses. Postoperative questionnaires and medical records were used to determine ability to perform activities 6 months after surgery. RESULTS: Of 194 participants (mean age = 74.9 ± 9.1 y), 57.7% were female; 33.5% had more than two comorbid conditions. We elicited 510 valued activities, with a mean of 2.6 (± .7) activities per participant. Content analysis revealed five categories: (1) recreational activities (28.9%); (2) mobility (24.9%); (3) activities of daily living (ADLs; 17.5%); (4) instrumental activities of daily living (IADLs; 16.9%); and (5) social activities (12.0%). Ultimately, 154 participants had surgery, of which 27.3% were unable to perform one of their valued activities at 6 months. Performance varied between activity categories; 91.9% of mobility activities, 90.8% of ADLs, 80.3% of IADLs, 77.3% of social activities, and 65.5% of recreational activities were able to be performed after surgery. CONCLUSION: Older adults expressed a wide range of valued life activities. More than one-quarter were unable to engage in at least one valued life activity after surgery, with recreation the most commonly affected. Assessment of valued life activities should be incorporated into the perioperative management of older adults. J Am Geriatr Soc 67:2305-2310, 2019.

Trajectories of Postoperative Depressive Symptoms in Older Patients Undergoing Major Surgery.

This cohort study examines the trajectories of postoperative depressive symptoms in older patients undergoing major surgery and the differences in patient characteristics between the trajectory groups.

Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative.

BACKGROUND: The American College of Surgeons Coalition for Quality in Geriatric Surgery is a multidisciplinary stakeholder group that aims to systematically improve the surgical care of older adults by establishing a verifiable quality improvement program with standards based on best evidence. Prior work confirmed the validity of a preliminary set of 308 standards to improve the quality of geriatric surgery, but concerns exist as to whether the standards are feasible for hospitals to implement. OBJECTIVE: Our aim was to utilize data gained from a multi-institutional survey and interview to improve the scalability and generalizability of a geriatric quality improvement program. METHODS: Using a survey followed by a targeted debrief interview, 15 hospitals gathered an interdisciplinary panel to answer whether each standard was already in place at their institution, and if not, the perceived difficulty of implementation according to a five-point Likert scale (from 1 [very easy] to 5 [very difficult]). The standards were then placed into categories according to the hospital responses. Standards were designated "duplicative" if 11 or more hospitals reported baseline implementation, "prohibitively difficult" if 6 or more hospitals rated the standard as such, and "high potential" if they were neither duplicative nor difficult. A targeted debrief interview was then conducted with each participating hospital. RESULTS: Fifteen participating hospitals evaluated the feasibility of 108 standards and found 28 (26%) duplicative, 35 (32%) too difficult, and 45 (42%) high potential. Of the 108 standards, 49 (45%) were selected for the next iteration of standards, and 59 were removed. Among the standards that were removed, the majority (64%) were rated duplicative and/or difficult. CONCLUSION: A multi-institutional survey and interview successfully identified care standards that were redundant or too difficult to implement on the hospital level. These data will help improve the generalizability and scalability of the program while maintaining the overall goal of improving care. J Am Geriatr Soc 67:1074-1078, 2019.

Increasing Advance Care Planning Using a Surgical Optimization Program for Older Adults.

OBJECTIVES: To describe an innovative model of care, the Surgery Wellness Program (SWP), that uses a multidisciplinary team to develop and implement preoperative care plans for older adults, and its effect on engagement in advance care planning (ACP). DESIGN: Retrospective analysis of clinical demonstration project. SETTING: 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 participants met with a geriatrician who engaged them in a semistructured ACP discussion. Trained medical and nurse practitioner students were used as health coaches who contacted participants regularly to address and document ACP. MEASUREMENTS: Self-report of ACP engagement before and after participation in the SWP was determined using SWP geriatrician and health coach progress notes. Medical records were examined for scanned documentation. Feasibility data on number of health coach calls were collected. RESULTS: After completion of the program, the proportion of participants with a designated surrogate increased from 67% to 78% (p<.001), completed advance directive (AD) from 51% to 72% (p<.001), and an AD scanned into the medical record from 14% to 60% (p<.001). Participants who underwent surgery received a median of 4 health coaching calls over a median of 27 days between their clinic visit and surgery. Case examples are presented to highlight how the SWP attends to the many components of the ACP process. CONCLUSION: Preoperative optimization programs provide a unique opportunity to engage older adults in ACP.

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans.

BACKGROUND: Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy. OBJECTIVES: To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008-09 compared to 2013-14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008-09 subgroup. DESIGN: Retrospective cohort study. SETTING: Urban Veterans Affairs Medical Center. PARTICIPANTS: 243 veterans age ≥65 with newly diagnosed pulmonary nodules in 2008-09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013-14. MEASUREMENTS: The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65-74 with CCI 0 while limited life expectancy was defined as age ≥85 with CCI ≥1 or age ≥65 with CCI ≥4. Interaction by nodule size was also examined. RESULTS: From 2008-09 to 2013-14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008-09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ≥4 versus 0: adjusted RR 0.61, 95% CI 0.39-0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48-1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ≤6 mm. CONCLUSIONS: We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.

Application of the RAND-UCLA Appropriateness Methodology to a Large Multidisciplinary Stakeholder Group Evaluating the Validity and Feasibility of Patient-Centered Standards in Geriatric Surgery.

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.

Postoperative Functional Outcomes in Older Adults.

As the world's aging population grows, the surgical population is increasingly made up of older adults. Due to changes in physiologic function and increasing comorbidity burden, older adults are at increased risk of morbidity, mortality, and functional decline after surgery. In addition, decision to undergo surgery for the older adult may be based on the postoperative functional outcome rather than survival. Although few studies have evaluated an older adult's function as a postoperative outcome, surgeons are becoming increasingly aware of the importance of maintaining or regaining function in an older patient. Interventions to improve postoperative functional outcomes are being developed and show promising results. This review discusses existing literature on postoperative functional outcomes in older adults and recently developed interventions.

Clinician Factors Associated With Prostate-Specific Antigen Screening in Older Veterans With Limited Life Expectancy.

IMPORTANCE: Despite guidelines recommending against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, PSA screening remains common. OBJECTIVE: To identify clinician characteristics associated with PSA screening rates in older veterans stratified by life expectancy. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 826 286 veterans 65 years or older eligible for PSA screening who had VA laboratory tests performed in 2011 in the VA health care system. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of men with a screening PSA test in 2011. Limited life expectancy was defined as age of at least 85 years with Charlson comorbidity score of 1 or greater or age of at least 65 years with Charlson comorbidity score of 4 or greater. Primary predictors were clinician characteristics including degree-training level, specialty, age, and sex. We performed log-linear Poisson regression models for the association between each clinician characteristic and PSA screening stratified by patient life expectancy and adjusted for patient demographics and clinician clustering. RESULTS: In 2011, 466 017 (56%) of older veterans received PSA screening, including 39% of the 203 717 men with limited life expectancy. After adjusting for patient demographics, higher PSA screening rates in patients with limited life expectancy was associated with having a clinician who was an older man and was no longer in training. The PSA screening rates ranged from 27% for men with a physician trainee to 42% for men with an attending physician (P < .001); 22% for men with a geriatrician to 82% for men with a urologist as their clinician (P < .001); 29% for men with a clinician 35 years or younger to 41% for those with a clinician 56 years or older (P < .001); and 38% for men with a female clinician older than 55 years vs 43% for men with a male clinician older than 55 years (P < .001). CONCLUSIONS AND RELEVANCE: More than one-third of men with limited life expectancy received PSA screening. Men whose clinician was a physician trainee had substantially lower PSA screening rates than those with an attending physician, nurse practitioner, or physician assistant. Interventions to reduce PSA screening rates in older men with limited life expectancy should be designed and targeted to high-screening clinicians- older male, nontrainee clinicians-for greatest impact.