Systematic Reviews of Surgical Comprehensive Geriatric Assessment and Assessment of Drivers of Cost in Elderly Emergency Surgery Patients

• Author / Creator

  Eamer, Gilgamesh J

• Aging populations are increasing the demand for surgical intervention in those over 65 years of age. Older patients experience higher morbidity and mortality. Comprehensive geriatric assessment (CGA) is a multi-faceted approach to in-patient care that addresses medical, functional and psychosocial factors. It is proposed to decrease cost and adverse outcomes in the elderly. I will investigate the effectiveness of CGA in published studies then examine the costs associated with emergency abdominal surgery in a cohort of elderly surgical patients. Two systematic reviews of CGA in surgical patients were conducted. Both examined CGA in surgical patients 65 and older. The primary outcomes for the Cochrane review were mortality and return of pre-morbid function. The primary outcome in the economic review was reported economic outcomes. We also retrospectively examined general surgical inpatient costs over two fiscal years at four hospitals within the Edmonton zone. Costs were compared between surgical risk profile, urgency and age. The Cochrane review found end-of-study mortality trended towards improvement and discharge disposition was significantly improved. Length of stay and readmission were unchanged and complications were decreased. The economic systematic review found lower cost while loss of function, length of stay and mortality were all reduced suggesting CGA may be the economically dominant choice when compared to usual care. All but one study in each review were in orthogeriatric patients; there are insufficient studies to draw conclusions about other surgical populations. Within the Edmonton zone, unscheduled cases were statistically and clinically significantly costlier for 65-79 and 80+ year-old age groups when compared to those under 65. Scheduled surgeries were not clinically significantly different between age groups. Economic evaluation of acute abdominal surgical patients aged 65 and older was conducted. Patients were prospectively enrolled in the Elder-friendly Approaches to the Surgical Environment (EASE) study at two Canadian hospitals in a trial of CGA versus usual surgical care. Baseline clinical, social and demographic characteristics were assessed. Follow-up was conducted at 6 weeks and 6 months following discharge. The Alberta Health Services (AHS) microcosting database along with other AHS and Alberta Health costing databases were used to calculate inpatient, readmission and total healthcare costs from enrolment to 6-months following discharge. Patient-reported resource use within 6 months of discharge was measured using a validated Health Resource Utilization Inventory (HRUI). The primary outcome for database costs analysis was total government healthcare costs; which was assessed using multivariate generalized linear regression. HRUI costs were assessed in a separate analysis with regression. Analysis of the costs accrued by patients enrolled in the EASE study found mean total government costs was $33,752. Multivariate regression found the cost of care increased with higher ASA (Adjusted ratio [AR]=1.24, p=0.002), higher frailty (AR=1.27, p<0.001) and both minor (AR=1.50, p<0.001) and major complications (AR=2.01, p<0.001). After controlling for clinical and demographic data, patients who completed the HRUI had frailty predicted increased cost of healthcare services (AR=1.50, p=0.001) and medical products (AR=1.62, p=0.005) and decreased cost in lost productive hours (AR=0.39, p=0.002). Complications did not predict any change in cost in any category. Overall, CGA is a promising tool to reduce the cost of care while improving outcomes in seniors undergoing unscheduled orthogeriatric procedures. Retrospective analysis identified increased surgical costs with age for unscheduled surgery. Screening elective surgical candidates may decrease admission costs; innovative programs are needed to reduce emergency admission costs. Frailty was also found to predict increased total government costs over 6-months and predicted increased cost of healthcare services and medical products. The EASE study is currently examining the effectiveness of CGA in an unscheduled general surgical population.

• Subjects / Keywords

  • Emergency
  • Surgery
  • Cost analysis
  • Geriatric

• Graduation date

  Fall 2017

• Type of Item

  Thesis

• Degree

  Master of Science

• DOI

  https://doi.org/10.7939/R3K931M2T

• License

  This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.