Hundreds of procedures qualify as "high-risk" for older patients

Last Updated: 2015-02-27

By Will Boggs MD

NEW YORK (Reuters Health) - By virtue of their inpatient mortality of at least 1%, 227 procedures qualify as "high-risk" for patients aged 65 years and older, researchers report.

"My main focus in writing this paper was to develop a list of procedures that can be used for research and quality improvement purposes," Dr. Margaret L. Schwarze from University of Wisconsin Hospital and Clinics in Madison told Reuters Health by email. "The main reason I see this paper is valuable is to use the collection of operations in a group to evaluate outcomes of similarly risky operations in a certain patient population."

"For example, our group is looking at how patients who have these operations and then have complications postoperatively fare over the following year," she said. "Others might want to look at how an intervention to improve quality changed surgical outcomes for this 'high-risk' group of operations."

Dr. Schwarze and colleagues used data from the Nationwide Inpatient Sample (NIS) to develop a list of operations that could be considered high-risk for older patients. They chose the 1% mortality threshold because that signifies substantial operative risk in the contemporary era.

Out of 264 procedures identified as high-risk by modified Delphi procedure, 227 procedures were confirmed in the NIS as being high-risk among patients 65 and older, the researchers report in JAMA Surgery, online February 18.

Two hundred fourteen of these procedures were identified as statistically significantly high-risk for all types of admissions of these older patients, whereas 10 were uniquely high-risk for older patients during emergent or urgent admissions only.

The pooled in-patient mortality for 154 procedures whose inpatient mortality was at least 1% among younger patients totaled 3% for the younger patients, compared with 6% for patients 65 years and older.

"Some of the procedures that are on this list surprised me, as a surgeon, a bit -- things like colon resection, which I don't usually think of as 'high risk,'" Dr. Schwarze said. "I think because this group is older the risk is higher and so it's helpful as a surgeon to remember that some things that you think of as typically less risky are a bit more risky in older patients."

"Our list provides a general notion of operative intrinsic risk, and additional risk calculators (e.g., the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator) designed for precise risk prediction are necessary to tailor individual risk discussions," the researchers note.

"Older adults make up a large and growing fraction of those patients now undergoing surgery in the US, and developing appropriate strategies for communicating and discussing the risks involved with surgery represents an important component of high-quality care for older surgical patients," Dr. Mark David Neuman, an anesthesiologist at the University of Pennsylvania in Philadelphia, told Reuters Health by email.

"These data provide important insights for physicians and patients seeking to understand what groups of patients may be at greatest risk of adverse outcomes and who might stand to benefit the most from initiatives focused on reducing surgical mortality and improving communication about the risks of surgery," said Dr. Neuman, who was not involved in the study.

"I think all surgeons need to be aware that with age the patients' physiological reserves are diminished and thus risk increases for both emergent and elective surgery," said Dr. Kjetil Søreide, a professor of surgery at the University of Bergen, Norway. "Elderly patient may tolerate the procedure, but not the potential associated complication(s) to that specific procedure. That being said, surgery can be performed safely in the elderly with proper pre-operative work-up and optimization of peri-operative measures."

The complete list of these high-risk procedures is available in the supplements to the published report.

SOURCE: http://bit.ly/1DhK9gB

JAMA Surg 2015.