Abstract
Older adults undergoing vascular surgery are particularly vulnerable to adverse outcomes by virtue of their vascular risk factors and medical comorbidities. This study aimed to determine the impact of daily medical liaison for patients aged 65 years and older admitted to a regional vascular surgery centre. This was a descriptive before-and-after study concerning 375 patients. The primary outcome measure was length of stay (LOS). Following intervention, we identified a reduction in mean LOS in the sample from 10.75 to 7.95 days (p = 0.635, 95% Confidence Interval [CI] 0–5 days) with a statistically significant reduction in mean LOS for “stranded” patients admitted for more than seven days (mean 7.84 days reduction, p = 0.025, 95% CI for mean difference, 1.5 to 14 days). These patients did not display elevated 30-day readmission rates (12/60 to 8/72, p = 0.156, 95% CI −3% to 21%). A non-significant reduction in postoperative complications was seen in all patients in the post-intervention cohort (1.09 to 0.86 per person, p = 0.181, 95% CI −0.11 to 0.56), reaching statistical significance in emergency vascular admissions (1.81 to 0.97 complications per person, p = 0.01, mean difference = 0.84, 95% CI 0.21–1.46). This study demonstrated reduced LOS and complications in selected older patients admitted under vascular surgery after the introduction of a daily medical liaison model. These data are amongst the first to reproduce randomised controlled trial findings in a non-trial setting. Subgroup analysis indicates that patients admitted with acute pathology and those with long LOS may benefit most from medical liaison where resources are finite.
Highlights
The proportion of older people undergoing surgery is increasing faster than the rate of population ageing [1,2]
This may indicate that patients who gain most from medical liaison are those admitted with acute pathology, and those who sustain a long length of stay
It was noted that discharge letters did not often comprehensively summarise key medical issues, potentially leading to the underreporting of complications. Another limitation was that the service was delivered during normal working hours (08:00–17:00, Monday to Friday) and, results must be interpreted with the understanding that outside of these hours, a reactive method was adopted which was reliant on acute services, such as ad hoc referral to the duty medical registrar. These data indicate that existing RCT results demonstrating the benefits of proactive medical liaison for complex older patients undergoing vascular surgery may be partially reproduced in a service development setting with modest resource allocation
Summary
The proportion of older people undergoing surgery is increasing faster than the rate of population ageing [1,2]. This is representative of advances in surgical and anaesthetic techniques. It is well established that older patients are more susceptible to adverse outcomes and those undergoing vascular surgery are a vulnerable, high-risk group [2,3]. This frequently reflects the Geriatrics 2020, 5, 78; doi:10.3390/geriatrics5040078 www.mdpi.com/journal/geriatrics. Distinct from older age and multimorbidity is frailty, a syndrome of vulnerability to minor stressors as a consequence of accumulated deficits over an individual’s lifetime leading to reduced physiological reserve. Frailty independently predicts adverse outcomes after major vascular surgery [4]
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