G. Eamer1, A. Taheri1, S. S. Chen1, Q. Daviduck1, T. Chambers2, R. G. Khadaroo1 1University Of Alberta,General Surgery,Edmonton, AB, Canada 2University Of Alberta,Libraries,Edmonton, AB, Canada
Introduction:
Aging world populations are increasing the demand for surgical intervention in those over 65 years of age. Older patients experience higher rates of post-operative complications, have longer length of stay, increased cost and are more likely to require institutionalization after discharge. 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.
Methods:
A Cochrane systematic search of MEDLINE, CENTRAL, Embase and the EPOC register for randomized controlled trials and controlled before-after studies of CGA versus usual care was conducted by a librarian. Grey literature was also searched. Two reviewers screened titles, full text and extracted data. Inclusion criteria include emergency or elective surgical patients over 65 receiving CGA versus usual care. Exclusion criteria include no patient cohorts over 65, wrong intervention, wrong setting, incorrect study design and incomplete geriatric assessment. Primary outcomes were predefined as mortality and return of pre-morbid function. Secondary outcomes were length of stay, post-operative complication rates, readmission and cost. Meta-analysis was performed assuming random effects and using the longest period from each study. Subgroup analysis analyzed orthopedic studies.
Results:
A total of 12,900 articles were identified; 12,580 were excluded based on abstract review and 310 after full text review. Ten articles from 8 studies were identified for inclusion. All studies were single center randomized controlled trials; 7 in orthopedics trauma and one in surgical oncology. Studies were published between 1988 and 2015. Orthopedic trials were analyzed as a subgroup and are reported below. There was a significant improvement in discharge disposition (OR 0.69, 95% CI 0.48-0.99, p=0.04, 6 studies, high quality evidence) and post-operative delirium (OR 0.52, 95% CI 0.31-0.88, p=0.02, 2 studies, high quality evidence). Mortality neared a significant reduction in the experimental group (OR 0.78, 95% CI 0.59-1.03, p=0.08, 5 studies, high quality evidence). There was no significant change in length of stay (mean difference -2.82, 95% CI -10.30-4.67, p=0.76, 5 studies, high quality evidence) or readmission (OR 0.92, 95% CI 0.53-1.57, p=0.75, 2 studies, moderate quality evidence). Only one study reported aggregate post-operative complications (OR 0.53, 95% CI 0.34-0.82).
Conclusion:
CGA demonstrates improved return of function and decreased post-operative delirium. Our meta-analysis found significant improvements in outcomes for orthopedic trauma patients over 65 and suggests orthogeriatric care with CGA should become the standard of care. There is insufficient information to determine if this finding applies to other surgical specialties or interventions. Further studies should examine the effectiveness of CGA in other surgical fields.