Optimising the care and treatment pathways of older patients facing major gastrointestinal surgery

Background
The population of patients presenting with gastrointestinal pathology amenable to surgery is becoming increasingly complex; patients are older, often with co-morbidities and functional or cognitive impairments that make treatment decision-making challenging. Lack of evidence-based guidelines mean that the assessment of an older patient for suitability for surgery, and subsequent optimisation to improve outcomes, is variable.
Methods
This mixed-methods study has looked at the evidence for pre-operative optimisation in older adults, explored what clinicians and healthcare professionals think about assessment and optimisation of older adults, assessed decision-making in hypothetical scenarios and studied current practice with functional outcomes. This has been achieved through a systematic review, semi-structured interviews, a national survey of practice with discrete choice experiment and an observational cohort study.
Results
A number of different interventions were identified in the pre-operative period with evidence that they may improve post-operative surgical outcomes. There were a limited number of studies focusing on the older population and heterogeneity of interventions and outcomes measures limited comparison of studies. Semi-structured interviews explored the barriers and facilitators to assessing and optimising older patients; these included lack of time in the surgical pathways, lack of resources and time in job plans and lack of high-quality evidence and guidelines to guide practice. The survey of practice demonstrated that current practice varies considerably; from use of objective testing, involvement of specialists in geriatric medicine and allied health professionals to the use of screening questionnaires. The Discrete Choice Experiment revealed the importance of key variables in treatment decision-making in older patients, with co-morbidities and cognitive impairment particularly important on binomial analysis. The observational cohort study demonstrated heterogeneity in the health and fitness status of older adults who underwent elective or emergency major gastrointestinal surgery and those who underwent non-resectional management pathways. Low provision of peri-operative optimisation strategies in practice was observed. Functional impairments after surgery were common.
Conclusions
Robust methods of assessing all patients are needed to ensure that those at risk of poor post-operative outcomes are identified early and interventions put in place. Lack of national guidelines and research evidence in older surgical patients limits the development of surgical pathways with interventions to improve outcomes. Variation in attitudes towards surgery in older adults, methods of assessment of fitness and optimisation practice amongst surgeons likely contributes towards variation in outcomes.