Project

Older Persons Surgical Outcomes Collaboration (OPSOC)

Goal: To improve outcomes for older patients who find themselves on a surgical list.


http://www.opsoc.eu/

Individual projects to follow, supported by work package leaders

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Project log

Jonathan Hewitt
added a research item
Background: Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge. Methods: The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level. Results: A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit. Conclusion: Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.
Ben Carter
added an update
Our ELF Study to link the care-level on discharge versus pre-surgery is currently back under review.
We have just submitted a response to the peer reviewers comments and we anticipate the manuscript being accepted shortly and will be published in the Autumn in a leading Surgical Journal
All the peer reviewers congratulated us and all the Elves who contributed to the study. I would like to continue to thank our Elves, as without the data quality that we ended with, we would not be in the position that we are in now.
Thank you!
 
Jonathan Hewitt
added a research item
Objective: This study aimed to document the prevalence of frailty in older adults undergoing emergency laparotomy and to explore relationships between frailty and postoperative morbidity and mortality. Summary background data: The majority of adults undergoing emergency laparotomy are older adults (≥65 y) that carry the highest mortality. Improved understanding is urgently needed to allow development of targeted interventions. Methods: An observational multicenter (n=49) UK study was performed (March-June 2017). All older adults undergoing emergency laparotomy were included. Preoperative frailty score was calculated using the progressive Clinical Frailty Score (CFS): 1 (very fit) to 7 (severely frail). Primary outcome measures were the prevalence of frailty (CFS 5-7) and its association to mortality at 90 days postoperative. Secondary outcomes included 30-day mortality and morbidity, length of critical care, and overall hospital stay. Results: A total of 937 older adults underwent emergency laparotomy: frailty was present in 20%. Ninety-day mortality was 19.5%. After age and sex adjustment, the risk of 90-day mortality was directly associated with frailty: CFS 5 adjusted odds ratio (aOR) 3.18 [95% confidence interval (CI), 1.24-8.14] and CFS 6/7 aOR 6·10 (95% CI, 2.26-16.45) compared with CFS 1. Similar associations were found for 30-day mortality. Increasing frailty was also associated with increased risk of complications, length of Intensive Care Unit, and overall hospital stay. Conclusions: A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age. Frailty scoring should be integrated into acute surgical assessment practice to aid decision-making and development of novel postoperative strategies.
Ben Carter
added an update
The ELF Study manuscript has now been accepted linking pre-admission frailty to postoperative outcome, congratulations to all you ELves out there...
Secondary Analyses are currently underway
 
Jonathan Hewitt
added an update
Ben Carter
added a research item
Background/objective: The impact of medications with anti-cholinergic properties on morbidity and mortality of unselected adult patients admitted to the emergency general surgical setting has not been investigated. Methods: All cases were identified prospectively from unselected adult patients admitted to the emergency general surgical ward between May to July 2016 in a UK centre with a catchment population circa 500,000. Prescribed medication lists were ascertained from case notes and electronic medical records. Anti-Cholinergic Burden (ACB) was calculated from medication lists. Patients were categorised into three groups based on ACB; none (ACB score of 0); moderate (up to ACB score of two); high (ACB score more than two). The effect of increasing ACB on selected outcomes of 30- and 90-day mortality, hospital readmission within 30-days of discharge and increased length of hospital stay were examined using multivariable logistic regression models. Results: The 452 patients had a mean age (SD) of 51.7 (±20.6) years, 273 (60.4%) patients had no ACB burden, 106 (23.5%) had a ACB burden of up to two; and 73 (16.2%) had an ACB burden of > 2. Multivariable analyses showed no association between high ACB burden and 90-day (fully adjusted odds ratio [OR] 0.56 (95%CI 0.12–2.85); P = 0.48) and 30-day mortality (fully adjusted OR = 0.75 (95%CI 0.05–11.04); P = 0.84). A significant association was observed between moderate ACB burden and 30-day hospital readmission (fully adjusted OR = 2.01 (95%CI 1.09–3.71); P = 0.03). Conclusions: Anti-cholinergic burden may be linked to hospital readmission in adults admitted to an emergency general surgical ward.
Ben Carter
added an update
Response to reviewers comments submitted
 
Ben Carter
added an update
Positive peer reviewer comments recieved. Watch this space for changing a mindset of who should undergo surgery, and who is of greatest risk of mortality
 
Ben Carter
added an update
Responded to reviewers comments - Good work Andrew
 
Ben Carter
added an update
Positive reviewers comments recieved
 
Ben Carter
added an update
Frailty in Older Patients undergoing Emergency Laparotomy: results from the observational ELF Study (Emergency Laparotomy and Frailty)
Well done all the elves - fantastic effort
Late and breaking ELF results last week
Submission underway ASAP. Watch this space
 
Ben Carter
added an update
Manuscript just accepted - Watch this space
 
Jonathan Hewitt
added 2 research items
Aim: The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients. Methods: Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only. Results: A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group. Conclusions: There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; ••: ••-••.
Jonathan Hewitt
added 2 research items
Introduction Impaired preoperative kidney function is associated with an increase in post-procedural major complications and mortality in older elective surgical population. However, little is known about the impact of poor kidney function on outcomes in emergency surgical setting in this age group. This study aimed to quantify the effect of impaired kidney function on 30 and 90 days mortality; and readmission within 30 days following an acute surgical admission in older patients. Material and methods The Older Persons Surgical Outcomes Collaboration 2015 cohort study, in four UK centres and one in Belgium, examined the above relationships. A logistic regression model was used to assess the odds of outcomes when comparing impaired eGFR to normal eGFR. A total of 402 patients were included with a mean age of 76.2 years (range 65–103 years), of which 209 (52%) were male. Results The prevalence of eGFR <60 ml/min/1.73 m² was 34.1% (N = 137). Patients with an eGFR of <60 ml/min/1.73 m² on admission were more likely to die at 30 and 90 days when compared to patients with eGFRs ≥60 ml/min/1.73 m²; respective adjusted OR = 2.98 (95%CI 1.38–6.43, P = 0.006) and 3.37 (95%CI 1.82–6.27, P < 0.001). No differences were observed for 30-day readmission to hospital. Conclusions Admission eGFR provides prognostic information which is useful to clinicians in an acute surgical setting. Whether closer monitoring and focused management at improving kidney function improves outcome in this patient population warrants further investigation.
Jonathan Hewitt
added a research item
Background We assessed the prevalence of frailty in an older acute general surgical population and its correlation with length of hospital stay, readmission to hospital and 30 and 90 day mortality. Methods In three acute surgical admissions units we assessed consecutive participants aged over 65 years with general surgical conditions. We measured the prevalence of frailty using a 7 point Frailty score. We measured length of hospital stay, readmission to hospital and mortality at both 30 and 90 days. Results We studied 325 participants with an average age of 77.3 years 8.2 (sd), 185 (57%) women. There were 88 (28%) who were classed as being mildly, moderately or severely frail. The frail group spent longer in hospital (7.6 days (6.1-9.2, 95%CI) vs 11.1 (7.2-15.0)), p=0.03). They also were more likely to die at both 30 and 90 days; Adjusted odds ratio 4.0 (1.1-15.2), p=0.04 and 3.0 (1.3-7.4), p=0.02. Readmission to hospital did not differ, OR 1.1 (0.5-2.3). Conclusions Over one in four people were frail. These individuals spent longer in hospital and were more likely to die.
Ben Carter
added an update
OPSOC Cohort Protocol Paper Just resubmitted
 
Jonathan Hewitt
added a research item
Objectives Multimorbidity is the presence of 2 or more medical conditions. This increasingly used assessment has not been assessed in a surgical population. The objectives of this study were to assess the prevalence of multimorbidity and its association with common outcome measures. Design A cross-sectional observational study. Setting A UK-based multicentre study, included participants between July and October 2014. Participants Consecutive emergency (non-elective) general surgical patients admitted to hospital, aged over 65 years. Outcome measures The outcome measures were (1) the prevalence of multimorbidity and (2) the association between multimorbidity and frailty; the rate and severity of surgery; length of hospital stay; readmission to hospital within 30 days of discharge; and death at 30 and 90 days. Results Data were collected on 413 participants aged 65–98 years (median 77 years, (IQR (70–84)). 51.6% (212/413) participants were women. Multimorbidity was present in 74% (95% CI 69.7% to 78.2%) of the population and increased with age (p<0.0001). Multimorbidity was associated with increasing frailty (p for trend <0.0001). People with multimorbidity underwent surgery as often as those without multimorbidity, including major surgery (p=0.03). When comparing multimorbid people with those without multimorbidity, we found no association between length of hospital stay (median 5 days, IQR (1–54), vs 6 days (1–47), (p=0.66)), readmission to hospital (64 (21.1%) vs 18 (16.8%) (p=0.35)), death at 30 days (14 (4.6%) vs 6 (5.6%) (p=0.68)) or 90-day mortality (28 (9.2%) vs 8 (7.6%) (p=0.60)). Conclusions and implications Multimorbidity is common. Nearly three-quarters of this older emergency general surgical population had 2 or more chronic medical conditions. It was strongly associated with age and frailty, and was not a barrier to surgical intervention. Multimorbidity showed no associations across a range of outcome measures, as it is currently defined. Multimorbidity should not be relied on as a useful clinical tool in guidelines or policies for older emergency surgical patients.
Ben Carter
added a project goal
To improve outcomes for older patients who find themselves on a surgical list.
Individual projects to follow, supported by work package leaders