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Background: To assess performance of the American College of Surgeons Geriatric Surgery Verification (GSV) Program preoperative communication standards in older patients undergoing high risk spine surgery. Methods: We performed an external validation of a natural language processing (NLP) method for identifying documentation meeting GSV communication standards. We then applied this method to a retrospective cohort of patients aged 65 and older who underwent spinal fusion procedures between January 2018–December 2020 in a large healthcare system in Massachusetts. Our primary outcome of interest was fulfillment of GSV communication domains: overall health goals, treatment goals, and patient‐centered outcomes. Factors associated with the fulfillment of at least one domain were assessed using Poisson regression to adjust for confounding. Results: External validation of the NLP method had a sensitivity of 88.6% and specificity of 99.0%. Our study population included 1294 patients, of whom only 0.8% (n = 10) patients contained documentation of all three GSV domains, and 33.7% (n = 436) had documentation fulfilling at least one GSV domain. The GSV domain with lowest frequency of documentation was overall health goals, with only 35 (2.7%) of patients meeting this requirement. Adjusted analysis suggested that patients with a Charlson comorbidity score of one or more had higher fulfillment of GSV criteria (CCI 1–3: prevalence rate ratio (PRR) 1.8, 95% confidence interval (CI) 1.5–2.1; CCI >3: PRR 1.5, 95% CI 1.2–1.9). Conclusion: A paucity of geriatric patients undergoing spine surgery had preoperative documentation consistent with GSV standards. Given that spine surgery is one of the highest risk surgeries in older adults and GSV standards are relevant to all surgical specialties, wider promulgation of these standards is warranted. [ABSTRACT FROM AUTHOR]

Introduction: Increasing numbers of individuals admitted to hospitals for trauma are older adults, many of whom also have underlying serious illnesses. Older adults with serious illness benefit from palliative care, but the palliative care needs of seriously ill older adults with trauma have not been elucidated. We hypothesize that older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours before trauma admission. Methods: Using Health and Retirement Study data (2008–2018) linked to Medicare claims, we identified patients 66 years or older who met an established definition of serious illness in surgery and were admitted with trauma. Descriptive analyses were performed for baseline patient characteristics, pre‐admission pain (dichotomized as none/mild vs. moderate/severe), depression (dichotomized as no, Center for Epidemiologic Studies Depression scale [CES‐D] < 3 vs. yes, CES‐D ≥ 3), and unpaid caregiving hours (dichotomized as low (<30 h/month), high (≥30 h/month)). Results: We identified 1741 patients, 67.4% were female and 86.8% White. Mean age was 83 (SD 7.5), and 60.3% had ≥4 comorbidities. The majority (62.9%) were admitted due to falls, 33.5% had isolated hip fracture. The prevalence of baseline moderate/severe pain and depression were 38.1% and 42.6%, respectively. Among the cohort, 42.2% had unpaid caregiving, of those 27.7% had ≥30 h/week of unpaid caregiving hours. Conclusions: Prior to trauma admission, older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours. These findings may inform targeted palliative care interventions to reduce symptom burden and post‐discharge healthcare utilization. [ABSTRACT FROM AUTHOR]

Background: Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019; Engelhardt et al., 2018). Methods: We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more. Results: Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements. Conclusion: Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives To apply the Frailty Phenotype ( FP) and Frailty Index ( FI) before major elective orthopedic surgery to categorize frailty status and assess associations with postoperative outcomes. Design Prospective cohort study. Setting Two tertiary hospitals in Boston, Massachusetts. Participants Individuals aged 70 and older undergoing scheduled orthopedic surgery enrolled in the Successful Aging after Elective Surgery ( SAGES) Study (N = 415). Measurements Preoperative evaluation included assessment of frailty using the FP and FI. The weighted kappa statistic was used to determine concordance between the two frailty measures and multivariable modeling to determine associations between each measure and postoperative complications, postoperative length of stay ( LOS) of longer than 5 days, discharge to postacute institutional care ( PAC), and 300 day readmission. Results Frailty was highly prevalent ( FP, 35%; FI, 41%). There was moderate concordance between the FP and FI ( κ = 0.42, 95% confidence interval ( CI) 0.36-0.49). When using the FP, being prefrail predicted greater risk of complications (relative risk ( RR) = 1.6, 95% CI = 1.1-2.1) and discharge to PAC ( RR = 1.8, 95% CI = 1.2-2.9) than being robust, and being frail predicted more complications ( RR = 1.7, 95% CI = 1.1-2.1), LOS longer than 5 days ( RR = 3.1, 95% CI = 1.1-8.8), and discharge to PAC ( RR = 2.3 95% CI = 1.4-3.7). When using FI, being prefrail predicted LOS longer than 5 days ( RR = 2.1, 95% CI = 1.0-4.8) and discharge to PAC ( RR = 1.5, 95% CI = 1.4-2.1), as did being frail ( RR = 1.9, 95% CI = 1.4-2.5; RR = 3.1, 95% CI = 1.4-6.8, respectively). The other outcomes were not significantly associated with frailty status. Conclusion FP and FI predict postoperative outcomes after major elective orthopedic surgery and should be considered for preoperative risk stratification. [ABSTRACT FROM AUTHOR]

Objective: Effective communication between intensive care unit (ICU) providers and families is crucial given the complexity of decisions made regarding goals of therapy. Using video images to supplement medical discussions is an innovative process to standardize and improve communication. In this six-month, quasi-experimental, pre-post intervention study we investigated the impact of a cardiopulmonary resuscitation (CPR) video decision support tool upon knowledge about CPR among surrogate decision makers for critically ill adults. Methods: We interviewed surrogate decision makers for patients aged 50 and over, using a structured questionnaire that included a four-question CPR knowledge assessment similar to those used in previous studies. Surrogates in the post-intervention arm viewed a three-minute video decision support tool about CPR before completing the knowledge assessment and completed questions about perceived value of the video. Results: We recruited 23 surrogates during the first three months (pre-intervention arm) and 27 surrogates during the latter three months of the study (post-intervention arm). Surrogates viewing the video had more knowledge about CPR ( p=0.008); average scores were 2.0 (SD 1.1) and 2.9 (SD 1.2) (out of a total of 4) in pre-intervention and post-intervention arms. Surrogates who viewed the video were comfortable with its content (81% very) and 81% would recommend the video. CPR preferences for patients at the time of ICU discharge/death were distributed as follows: pre-intervention: full code 78%, DNR 22%; post-intervention: full code 59%, DNR 41% ( p=0.23). [ABSTRACT FROM AUTHOR]

The article discusses a study conducted to know whether physicians, the group most familiar with end-of-life care, receive higher or lower intensity end-of-life treatments in comparison with nonphysicians. The study found that physicians received significantly less intensive care than the general population for 3 of 5 end-of-life care intensity measures and study limitations include omission of unmeasured confounders by controlling hospital referral region.

Background: Recent reports have raised concerns that public reporting of 30-day mortality after cardiac surgery may delay decisions to withdraw life-sustaining therapies for some patients. The authors sought to examine whether timing of mortality after coronary artery bypass graft surgery significantly increases after day 30 in Massachusetts, a state that reports 30-day mortality. The authors used New York as a comparator state, which reports combined 30-day and all in-hospital mortality, irrespective of time since surgery.Methods: The authors conducted a retrospective cohort study of patients who underwent coronary artery bypass graft surgery in hospitals in Massachusetts and New York between 2008 and 2013. The authors calculated the empiric daily hazard of in-hospital death without censoring on hospital discharge, and they used joinpoint regression to identify significant changes in the daily hazard over time.Results: In Massachusetts and New York, 24,864 and 63,323 patients underwent coronary artery bypass graft surgery, respectively. In-hospital mortality was low, with 524 deaths (2.1%) in Massachusetts and 1,398 (2.2%) in New York. Joinpoint regression did not identify a change in the daily hazard of in-hospital death at day 30 or 31 in either state; significant joinpoints were identified on day 10 (95% CI, 7 to 15) for Massachusetts and days 2 (95% CI, 2 to 3) and 12 (95% CI, 8 to 15) for New York.Conclusions: In Massachusetts, a state with a long history of publicly reporting cardiac surgery outcomes at day 30, the authors found no evidence of increased mortality occurring immediately after day 30 for patients who underwent coronary artery bypass graft surgery. These findings suggest that delays in withdrawal of life-sustaining therapy do not routinely occur as an unintended consequence of this type of public reporting. [ABSTRACT FROM AUTHOR]

Context: Optimal surgical care for older adults with life-threatening conditions, with high risk of poor perioperative outcomes and morality in the months after surgery, should incorporate an understanding of the patient's treatment goals and preferences. However, little research has explored the patient perspective of decision making and advanced care planning during an emergency surgery episode.Objectives: We sought to better understand older patients' lived experience making decisions to undergo emergency general surgery (EGS) and perceptions of perioperative advance care planning (ACP).Methods: Adults aged 65 and older who underwent one of seven common EGS procedures with lengths of stay more than five days at three Boston-area hospitals were included. Semistructured phone interviews were conducted three months postdischarge. Transcripts were reviewed and coded independently by surgeons and palliative care physicians to identify themes.Results: About 31 patients were interviewed. Patients viewed the decision for surgery as a choice of life over death and valued prolonging life. They felt there was no choice but to proceed with surgery but reported that participation in decision making was limited because of severe symptoms, time constraints, and confused thinking. Despite recently surviving a life-threatening illness, patients had not reconsidered their wishes for the future and preferred to avoid future ACP.Conclusion: Older patients who survived a life-threatening illness and EGS report receiving goal-concordant care in the moment that relieved symptoms and prolonged life but had not considered future care. Interventions to facilitate postoperative ACP should be targeted to this vulnerable group of older adults. [ABSTRACT FROM AUTHOR]

Background: Surgical patients with limited digital literacy may experience reduced telemedicine access. We investigated racial/ethnic and socioeconomic disparities in telemedicine compared with in-person surgical consultation during the coronavirus disease 2019 (COVID-19) pandemic., Study Design: Retrospective analysis of new visits within the Division of General & Gastrointestinal Surgery at an academic medical center occurring between March 24 through June 23, 2020 (Phase I, Massachusetts Public Health Emergency) and June 24 through December 31, 2020 (Phase II, relaxation of restrictions on healthcare operations) was performed. Visit modality (telemedicine/phone vs in-person) and demographic data were extracted. Bivariate analysis and multivariable logistic regression were performed to evaluate associations between patient characteristics and visit modality., Results: During Phase I, 347 in-person and 638 virtual visits were completed. Multivariable modeling demonstrated no significant differences in virtual compared with in-person visit use across racial/ethnic or insurance groups. Among patients using virtual visits, Latinx patients were less likely to have video compared with audio-only visits than White patients (OR, 0.46; 95% CI 0.22-0.96). Black race and insurance type were not significant predictors of video use. During Phase II, 2,922 in-person and 1,001 virtual visits were completed. Multivariable modeling demonstrated that Black patients (OR, 1.52; 95% CI 1.12-2.06) were more likely to have virtual visits than White patients. No significant differences were observed across insurance types. Among patients using virtual visits, race/ethnicity and insurance type were not significant predictors of video use., Conclusion: Black patients used telemedicine platforms more often than White patients during the second phase of the COVID-19 pandemic. Virtual consultation may help increase access to surgical care among traditionally under-resourced populations., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship is not well established. The primary goals of this study were to describe the prevalence of postoperative cognitive dysfunction and to investigate its association with in-hospital delirium. The authors hypothesized that delirium would be a significant risk factor for postoperative cognitive dysfunction during follow-up., Methods: This study used data from an observational study of cognitive outcomes after major noncardiac surgery, the Successful Aging after Elective Surgery study. Postoperative delirium was evaluated each hospital day with confusion assessment method-based interviews supplemented by chart reviews. Postoperative cognitive dysfunction was determined using methods adapted from the International Study of Postoperative Cognitive Dysfunction. Associations between delirium and postoperative cognitive dysfunction were examined at 1, 2, and 6 months., Results: One hundred thirty-four of 560 participants (24%) developed delirium during hospitalization. Slightly fewer than half (47%, 256 of 548) met the International Study of Postoperative Cognitive Dysfunction-defined threshold for postoperative cognitive dysfunction at 1 month, but this proportion decreased at 2 months (23%, 123 of 536) and 6 months (16%, 85 of 528). At each follow-up, the level of agreement between delirium and postoperative cognitive dysfunction was poor (kappa less than .08) and correlations were small (r less than .16). The relative risk of postoperative cognitive dysfunction was significantly elevated for patients with a history of postoperative delirium at 1 month (relative risk = 1.34; 95% CI, 1.07-1.67), but not 2 months (relative risk = 1.08; 95% CI, 0.72-1.64), or 6 months (relative risk = 1.21; 95% CI, 0.71-2.09)., Conclusions: Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.

Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women's Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early experiences., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)