Streamlined Tool Speeds Appraisal of Seniors' Postop Risks

Diana Swift

August 29, 2017

A pared-down, easily administered version of the Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA) tool reliably estimates the risk for geriatric and surgical complications in elderly patients, according to a new study published online August 2 in JAMA Surgery.

The prospective study drew on a cohort of 770 patients (384 women) with a mean age of 77.7 years, all of whom were scheduled to undergo elective surgery in the University of Michigan Health System, Ann Arbor, between July 2008 and January 2011. The most common surgery categories were otolaryngology/oral maxillofacial, plastic, and gastrointestinal.

The standard VESPA tool includes 14 items. For the current study, the team used an abbreviated version for preoperative assessment of functional status across the five activities of daily living proposed by the American College of Surgeons and the American Geriatrics Society: bathing, transferring, dressing, shopping, and meals. They also inquired about history of falling or gait impairment, as well as depressive symptoms, using the 2-item Patient Health Questionnaire-2. In addition, they administered a 3-minute cognitive examination (Mini-Cog) plus a gait/balance assessment (Timed Up and Go test).

A total of 736 patients underwent a preoperative assessment via the abbreviated VESPA, which was administered by physician assistants in 10 minutes or less.

Adding a novel question on self-care, the researchers also asked participants whether they thought they could manage for themselves on their own after discharge. "To our knowledge, this is the first study incorporating patients' self-assessed inability to manage themselves after an operation," write Lillian Min, MD, MSHS, from the Division of Geriatric and Palliative Medicine at the University of Michigan in Ann Arbor, and colleagues.

During evaluation, 105 patients (14.3%) had reported having at least one difficulty with the five activities of daily living, while 270 (38.2%) of 707 patients had self-assessed as being unable to manage postdischarge self-care alone.

After surgery, 187 of 740 patients (25.3%) turned out to have either geriatric or surgical complications, with 131 (17.7%) having geriatric complications and 114 (15.4%) having surgical complications. Men were almost twice as likely as women to have geriatric complications (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 - 2.8) in an unadjusted analysis.

"Without screening, we would have missed one-fourth of patients with a preoperative functional deficit and 38% with a novel risk factor: those who judged themselves as not being able to manage themselves alone after discharge," the investigators write. These two variables both correlated significantly with postoperative complications, a finding that parallels other research on the effect of frailty on surgical outcomes and highlights the advisability of system-wide screening efforts.

The study combined variables into three composite outcomes: any postsurgical occurrence, including acute renal failure, pneumonia, surgical site infection, unplanned intubation, sepsis, or urinary tract infection; death, or unplanned readmission within 30 days; any geriatric complication such as delirium, pressure ulcer, fall, or malnutrition; and any complication, whether surgical or geriatric.

On multivariable analysis, the number of reported difficulties with daily activities (OR, 1.3; 95% CI, 1.0 - 1.6), predicted difficulty with postoperative self-care (OR, 1.6; 95% CI, 1.0 - 2.2). Apart from male sex, other independent predictors of postoperative complications were a Charlson Comorbidity score of 2 or more (OR, 1.5; 95% CI, 1.0 - 2.3) and highly complex primary surgery (OR, 7.4; 95% CI, 4.6 - 11.9).

Using a cutoff score of 9 or higher, the investigators found the shorter VESPA scale had an acceptable specificity for postoperative complications of 76% and a sensitivity of 68%. The evaluation rate, however, steadily declined, from 42.3% of eligible patients during the first 6 months to 10.9% by the end of the study.

The 10-minute VESPA is in the process of being implemented in the University of Michigan's preoperative clinics. "We believe it will ease screening and be as effective [as the longer version]," coauthor Kathy M. Diehl, MD, from the Department of Surgery, told Medscape Medical News. "Thus far, the reaction from clinicians has been favorable."

"We expect that this more efficient version of the VESPA tool will facilitate sustainability of assessment rates in the future," the authors write, adding that further validation is warranted.

This research was supported by a grant from the University of Michigan Older Americans Independence Act Claude D. Pepper Center. Dr Min also received support from a Pepper Center Research Career Development Core grant and the Hartford Foundation Center of Excellence. The funding sources had no role in any aspect of the study. One author reports holding shares in Ooney Inc. The remaining authors have disclosed no relevant financial relationships.

JAMA Surg. Published online August 2, 2017. Abstract

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