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Relationship Between Asking an Older Adult About Falls and Surgical Outcomes

Teresa S. Jones, MD1; Christina L. Dunn, BA1; Daniel S. Wu, MD1; Joseph C. Cleveland Jr, MD1,2; Deidre Kile, MS3; Thomas N. Robinson, MD, MS1,2
[+] Author Affiliations
1Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
2Denver Veterans Affairs Medical Center, Denver, Colorado
3Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus, Aurora, Colorado
JAMA Surg. 2013;148(12):1132-1138. doi:10.1001/jamasurg.2013.2741.
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Importance  More than one-third of all US inpatient operations are performed on patients aged 65 years and older. Existing preoperative risk assessment strategies are not adequate to meet the needs of the aging population.

Objectives  To evaluate the relationship of a history of falls (a geriatric syndrome) to postoperative outcomes in older adults undergoing major elective operations.

Design, Setting, and Participants  This prospective, cohort study was conducted at a referral medical center. Persons aged 65 years and older undergoing elective colorectal and cardiac operations were enrolled. The predictor variable was having fallen in the 6 months prior to the operation.

Main Outcomes and Measures  Postoperative outcomes measured included 30-day complications, the need for discharge institutionalization, and 30-day readmission.

Results  There were 235 subjects with a mean (SD) age of 74 (6) years. Preoperative falls occurred in 33%. One or more postoperative complications occurred more frequently in the group with prior falls compared with the nonfallers following both colorectal (59% vs 25%; P = .004) and cardiac (39% vs 15%; P = .002) operations. These findings were independent of advancing chronologic age. The need for discharge to an institutional care facility occurred more frequently in the group that had fallen in comparison with the nonfallers in both the colorectal (52% vs 6%; P < .001) and cardiac (62% vs 32%; P = .001) groups. Similarly, 30-day readmission was higher in the group with prior falls following both colorectal (P = .04) and cardiac (P = .02) operations.

Conclusions and Relevance  A history of 1 or more falls in the 6 months prior to an operation forecasts increased postoperative complications, the need for discharge institutionalization, and 30-day readmission across surgical specialties. Using a history of prior falls in preoperative risk assessment for an older adult represents a shift from current preoperative assessment strategies.

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Figure 1.
Study Enrollment Flowchart
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Figure 2.
Prior Falls and Postoperative Complications in Colorectal Operations
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Figure 3.
Falls: The First Clue of Surgical Outcomes Database Modifications Needed to Accommodate Older Adults

The traditional variables used to quantify surgical risk include chronic diseases and single end-organ dysfunction (left). These variables are amenable to retrospective medical record review collection by looking at the surgeon’s history/physical note or the preanesthesia evaluation and, as a result, are currently used by the National Surgical Quality Improvement Program (NSQIP) data set to forecast surgical risk. Relying solely on chronic disease burden to quantify surgical risk in older adults is inadequate. Frailty-specific variables reveal reduced physiologic reserve specific to the older adult (right). These frailty variables are not currently used in surgical risk calculators because they are not commonly recorded in the surgical medical record and, therefore, cannot be collected through retrospective medical record review. There are few variables that both quantify the unique physiologic vulnerability of the older adult and can be collected by retrospective medical record review, which allows for their inclusion in surgical outcomes data sets (area where circles overlap). Potential variables to include in a geriatric-specific surgical outcomes data set are listed in the bottom box. These variables are often accessible by reading nursing inpatient admission notes, which include nutrition, mobility, and fall and pressure sore risk assessments. Examples of 2 commonly recorded nursing assessment scales include (1) the Morse Fall Risk Score (used to quantify inpatient fall risk), which documents fall history, ambulatory aid use, gait/transfer difficulties, and mental status; and (2) the Braden Score (used to quantify pressure sore risk), which documents activity, mobility, and nutrition. COPD indicates chronic obstructive pulmonary disease.

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