Feasibility and effectiveness of an evidence-based intervention bundle to improve peri-operative care of older adults

Abstract

BACKGROUND Maintaining functional status is an essential therapeutic goal in peri-operative care of older adults. Although several recommendations concerning peri-operative management are available, pragmatic approaches to their sustainable implementation are lacking. OBJECTIVE Multiple evidence-based recommendations for peri-operative care of older adults were bundled into a multicomponent intervention and assessed for feasibility and effectiveness. DESIGN A quality improvement study with before–after comparison using a hybrid implementation-effectiveness approach. SETTING University Medical Centre. The trial was conducted from 2017 to 2020, follow-up was 1 week, 1 month and 6 months after surgery. PATIENTS Patients at least 65 years old were scheduled for surgery; excluded: intercranial, ophthalmological, and emergency surgery; planned postoperative stay in the intensive care unit. A total of 720 patients were eligible; 278 patients were recruited, 95 (34) of whom were female. INTERVENTIONS The intervention consisted of a set of recommended measures for peri-operative management of older patients, including pre-operative assessment and measures to manage frailty, malnutrition, polypharmacy, cognitive impairment and delirium. Patients were sequentially assigned to three groups: control (no change from usual care), transition (to implementation of the intervention) and intervention (fully implemented). MAIN OUTCOME MEASURES Feasibility was assessed by determining the level of implementation, and barriers were identified by conducting qualitative interviews with the medical staff. Intervention effectiveness was estimated by Instrumental Activities of Daily Living (IADL; Lawton and Brody, primary clinical outcome) 1 and six months postoperatively. The secondary outcomes included postoperative complications, cognitive performance, quality of life and length of hospital stay. RESULTS The implementation rate was 77%. Pre-operative IADL was 9.9/10 (range 8 to 10; SD 0.4) and 9.7/10 (6 to 10, 0.8) for the control and intervention groups, respectively. There was no statistically significant difference between the groups in IADL (0.07, 95% CI −0.23 to 0.36, P = 0.66) and 6 months after surgery (0.01, 95% CI −0.29 to 0.31, P = 0.95). CONCLUSION The implementation of evidence-based interventions to improve peri-operative care of older patients showed good feasibility in clinical routine but did not improve patients’ functional status, which was already at a high level pre-operatively. TRIAL REGISTRATION ClinicalTrials.gov, Identifier: NCT03325413