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The Geriatric Surgery Verification Program

BY LINDSEY ZHANG, MD, MARCUS ESCOBEDO, MPA, and MARCIA M. RUSSELL, MD

The United States is in the midst of an unprecedented growth of the older adult population. As life expectancy increases and baby boomers enter their seventh and eighth decades, it is expected that 18 million people will turn 65 in the next ten years.¹ Although a greater proportion of older adults is a reflection of the many health care advances seen over the last half century, the medical community is now faced with the challenge of how to best care for older patients.

Providing safe and high-quality geriatric care is a mission that has been embraced by surgeons, as adults 65 and older now account for more than 40% of the surgical volume in the U.S. and are anticipated to have growing operative needs.^{2, 3, 4} The American College of Surgeons, a professional organization dedicated to improving care of the surgical patient, has responded to this need by developing the Geriatric Surgery Verification Quality Improvement Program. This program was created through the collaborative efforts of the American College of Surgeons, The John A. Hartford Foundation, and nearly 60 stakeholder organizations representing patients, caregivers, providers and payers. These groups worked together over four years to compile a set of expert-vetted and evidenced-based standards of care, focused on what matters most to older adults.^{5, 6}

The Geriatric Surgery Verification Program is centered on four main aspects of geriatric surgical care: goals and decision making; cognition and preventing postoperative delirium; maintaining function and mobility; and optimizing nutrition and hydration. These four areas pre-date but overlap extensively with the framework of the Age-Friendly Health Systems initiative, which the Catholic Health Association is currently promoting.⁷ The areas were chosen through in-depth discussions with stakeholder organizations and extensive literature review, which highlighted that respect for goals of care, preservation of physical and cognitive function and maintenance of independence are among the most important outcomes for older surgical patients.^{8, 9, 10} However, consideration of these outcomes is rarely prioritized in the preoperative decision-making process and sometimes overlooked entirely during the surgical encounter. The Geriatric Surgery Verification Program strives to change this status quo and challenges all hospitals to transform the way that they provide surgical care to older adults.

The impact of the program can first be seen in the preoperative phase of care. Traditionally, when an older adult presents to the surgical clinic for evaluation, the surgeon asks about the patient's physical symptoms, their medical history, allergies and medications. A physical exam is performed, and a decision is made regarding the patient's appropriateness for an operation. In a Geriatric Surgery Verification hospital, this model is revised to prioritize the patient's perspective. The program requires that surgeons ask the patient about treatment and overall health goals, and to discuss the anticipated impact of the operation, not only on survival, but on symptoms, function, independence and quality of life. Thus, considering whether surgery is the right choice for the patient becomes less of a paternalistic verdict from the surgeon and more of a patient-centered decision focused on the outcomes that older adults value. In addition to considering goals of care, older patients presenting to Geriatric Surgery Verification hospitals must be screened for high-risk geriatric-specific vulnerabilities (for example, impaired cognition or mobility), and a plan must be made to address these issues when they are detected.

After surgery, the program continues to ensure that older patients receive care that is patient-centered and designed to address their unique vulnerabilities. This includes mandating early and efficient return of glasses, hearing aids and other sensory devices immediately after surgery, providing protocols to avoid potentially inappropriate medications and encourage multi-modal pain management, and standardizing postoperative care to focus on preventing delirium, encouraging early mobility, and avoiding malnutrition and dehydration. Furthermore, the Geriatric Surgery Verification Program recognizes that patients who are identified as high-risk on preoperative screening assessments are more likely to suffer adverse outcomes after surgery. Thus, the program requires that such patients receive postoperative care from an interdisciplinary team, including a provider with geriatrics expertise. Importantly, this aspect of the Geriatric Surgery Verification Program highlights that improving geriatric surgical care is not about avoiding operations on high-risk older adults all together, but rather to recognize high-risk patients earlier, to make sure the patient's goals are aligned with the potential outcomes after surgery, and to design interdisciplinary postoperative care that works to prevent negative outcomes such as cognitive or functional decline and loss of independence.

When the older surgical patient is ready for discharge, Geriatric Surgery Verification hospitals understand that the recovery journey is far from over. They focus on educating patients and caregivers on expectations after they leave the hospital. Additionally, for patients who are unable to return home after surgery, the transition to post-acute care facilities can be challenging with a lack of transparency and understanding of what happens to patients once they leave the hospital. The Geriatric Surgery Verification Program asks hospitals to address these issues with protocols for two-way communication and tracking the quality of care provided at these facilities. The goal of improving transitions of care is to both expedite recovery and decrease unnecessary hospital readmissions. Finally, as a quality initiative, the program requires the measurement and collection of data on important geriatric outcomes, such as postoperative delirium and declines in physical and cognitive function, to help hospitals engage in continuous quality improvement on outcomes that matter most to older adults.

The development of the Geriatric Surgery Verification program emphasizes that with an aging population comes an opportunity to revolutionize the way we care for older adults and to make a meaningful impact on this vulnerable population. By joining the Geriatric Surgery Verification program and implementing these evidence-based, patient-centered standards, more hospitals can join this transformation to improve the surgical experience for older adults and focus on outcomes that matter to them.

To learn more about the Geriatric Surgery Verification Program, visit www.facs.org/geriatrics or send us an email at [email protected].

The authors would like to acknowledge GSV Core Development Team members JOANN COLEMAN, DNP ACNP; EMILY FINLAYSON, MD; MARK KATLIC, MD; SANDHYA LAGOO-DEENADAYALAN, MD, PHD; MEIXI MA, MD; THOMAS ROBINSON, MD; VICTORIA TANG, MD; and RONNIE ROSENTHAL, MD, as well as ACS staff members KATARYNA CHRISTENSEN; GENEVIEVE RANIERI, MSN, RN; SAMEERA ALI, MPH; and CLIFFORD KO, MD, for their contributions to this article.

1. Mark Mather, Linda A. Jacobsen and Kelvin M. Pollard, "Aging in the United States," Population Bulletin 70, no. 2 (2015): 1-18.
2. David A. Etzioni et al., "The Aging Population and Its Impact on the Surgery Workforce," Annals of Surgery 238, no. 2 (August 2003): 170–77, https://doi.org/10.1097/01.SLA.0000081085.98792.3d.
3. David A. Etzioni et al., "Impact of the Aging Population on the Demand for Colorectal Procedures," Diseases of the Colon & Rectum 52, no. 4 (April 2009): 583–90, https://doi.org/10.1007/DCR.0b013e3181a1d183.
4. Centers for Disease Control and Prevention, "Number of Discharges from Short-Stay Hospitals, by First-Listed Diagnosis and Age: United States, 2010," www.cdc.gov/nchs/data/nhds/3firstlisted/2010first3_numberage.pdf.
5. Julia R. Berian et al., "Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report from the Coalition for Quality in Geriatric Surgery," Annals of Surgery 267, no. 2 (February 2018): 280–90, https://doi.org/10.1097/SLA.0000000000002185.
6. Melissa A. Hornor et al., "Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative," Journal of the American Geriatrics Society 67, no. 5 (May 2019): 1074–78. https://doi.org/10.1111/jgs.15815.
7. Creating Age-Friendly Health Systems. Catholic Health Association of the United States. https://www.chausa.org/eldercare/creating-age-friendly-health-systems. Accessed March 3, 2020.
8. Cynthia Hofman et al., "The Influence of Age on Health Valuations: The Older Olds Prefer Functional Independence While the Younger Olds Prefer Less Morbidity," Clinical Interventions in Aging (July 2015): 1131-39, https://doi.org/10.2147/CIA.S78698.
9. Terri R. Fried et al., "Understanding the Treatment Preferences of Seriously Ill Patients," New England Journal of Medicine 346, no. 14 (April 4, 2002): 1061–66. https://doi.org/10.1056/NEJMsa012528.
10. Julia R. Berian et al., "Association of Loss of Independence with Readmission and Death after Discharge in Older Patients after Surgical Procedures," JAMA Surgery 151, no. 9 (September 21, 2016): e161689. https://doi.org/10.1001/jamasurg.2016.1689.