June 3, 2011 Hospitals that provide quality care for young people do not always provide the same quality care for the elderly, a new study has found.
As our population ages and requires more healthcare, hospitals need to measure the quality of care they provide for the over 65s and implement programs to meet their distinct needs, said the study's author, Dr. Avery Nathens, trauma director at St. Michael's Hospital.
The study, published in the June issue of the Journal of the American College of Surgeons, evaluated the condition of elderly patients 30 days after they underwent emergency surgery. Not surprisingly, it found these patients had a significantly higher risk of serious morbidity and mortality compared to younger patients.
What was surprising was that centers that provided high quality care for the young did not necessarily do so for the elderly. "This suggests that some hospitals put into place something unique that better addresses the needs of elderly patients," said Dr. Nathens. "What's put into place, however, is not quite clear."
Previous studies have shown that steps can be taken to improve patient outcomes for elderly people undergoing elective surgery, such as consultation and pre-surgical testing to reduce the risk of heart attacks and strokes, aggressive medical management and, in the United States, referrals to clinics that perform high volumes of the most complex procedures.
These options are not available to elderly patients who require emergency surgery, so hospitals must find other ways of providing them with quality care, Dr. Nathens said.
He said the study speaks to the importance of developing measures that specifically focus on the quality of care delivered to older patients. This study and others have shown that , this is probably one of the only ways we can be certain that the elderly are receiving the care they need.
"Much like we report on hospital performance in other areas, we need to provide assurance that hospitals are providing high quality care to some of their highest risk patients," said Dr Nathens. This would provide hospitals with the information they need to develop strategies to provide better care to these patients.
When it comes to emergency surgical patients, one strategy could be more collaboration with geriatricians.
In St. Michael's Trauma Program, a geriatrician sees every patient over 60 who experiences a major injury and makes recommendations regarding their care and treatment. This program -- the first of its kind in Canada -- has shown significant benefits, with fewer consultation requests to internal medicine and psychiatry, meaning more efficient care, and a reduction in delirium, which can be common among elderly hospital patients, costly, preventable, and associated with higher morbidity and mortality. Most importantly, fewer elderly patients are being discharged from the hospital to long-term care facilities than before the partnership with geriatrics began in 2007.
In addition, all patients over 65 are given a risk of fall assessment and a frailty assessment before being sent home.
"This work highlights the need for enhancing quality of care for older people and the need for more geriatricians," said Dr. Camilla Wong, a geriatrician in St. Michael's Geriatric Trauma Consultation Service.
"We don't have very many in Canada -- fewer than 0.5 for every 10,000 people over age 65. Compared with the U.S., the U.K. and Europe, we have a significant shortage of geriatricians, especially considering the increasing proportion of older people in Canada"
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- Angela M. Ingraham, Mark E. Cohen, Mehul V. Raval, Clifford Y. Ko, Avery B. Nathens. Variation in Quality of Care after Emergency General Surgery Procedures in the Elderly. Journal of the American College of Surgeons, 2011; 212 (6): 1039-1048 DOI: 10.1016/j.jamcollsurg.2011.03.001
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