Emergency General Surgery (EGS) procedures are among the most morbid and common operations in older adults. Postoperative mortality risk in older EGS patients is 3 times higher than for older patients after elective surgery, and 2-7 times higher than for younger EGS patients. Moreover, up to half of older EGS patients experience postoperative complications and most are discharged to nursing homes. With demographic shifts, the rate of EGS in older adults is expected to increase. However, outcomes that are particularly relevant to older EGS patients such as survival beyond 30-days, functional and cognitive trajectories, quality of life, and palliative care needs are unknown. This proposal addresses these knowledge gaps utilizing multiple data sources and complementary methodologies. First, Medicare Claims will be used to examine 12-month survival and health care utilization in a national cohort. Second, primary prospective data will be collected from a cohort of older EGS patients and their proxies to examine key outcomes unavailable in secondary datasets including symptom burden, functional and cognitive status, quality of life, advance care planning, and quality of end-of- life care. Third, qualitative analyses of semi-structured interviews with patients and proxies will be done to obtain a richer understanding about their lived experience.
The Specific Aims are: 1. To use National Medicare Claims to describe 12-month outcomes including survival, post-acute nursing home use, rehospitalization, and hospice use in older EGS patients (N=650,157), identify factors associated with better outcomes, and to compare these outcomes in a propensity-matched cohort of patients emergently hospitalized for three common medical conditions (pneumonia, congestive heart failure, and myocardial infarction, N=2,013,861); 2. To prospectively follow a cohort of older EGS patients (n~150) and their proxies (n~150) up to 12 months after surgery, to identify modifiable factors associated with fewer hospital transfers, better quality of life, and better end-of-life care; and, 3. To use a phenomenological approach to qualitatively analyze semi- structured interviews with patients (N=20) and proxies (N=20) from the cohort in Aim 2, to obtain an in-depth understanding of opportunities to improve post-surgical care in the following domains: quality of provider communication, advance care planning, symptom management, care transitions, and proxy experience. IMPACT: This work represents key steps in improving surgical care for older EGS patients by directly informing individual clinical decisions, setting expectations for recovery, helping to plan subsequent heath care needs, and revealing targets to improve surgical care delivery and palliative care for these patients. Finally, the work will establish the applicant as one of the few surgical health services researchers with expertise in aging and palliative care, and will prepare her to become an independent R01-funded investigator.

Public Health Relevance

Emergency general surgery for conditions such as small bowel obstruction and cholecystitis are among the most common and morbid operations performed in older adults. As the population ages, increasing numbers of are expected to undergo these burdensome procedures, yet little is known about outcomes beyond 30-day mortality which are particularly relevant to older patients. The goal of this proposal is to fully characterize the clinical trajectories, healthcare needs, illness experience and end-of-life care of older patients during the first year after emergency general surgery.

National Institute of Health (NIH)
National Institute on Aging (NIA)
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Special Emphasis Panel (ZAG1)
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Salive, Marcel
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Brigham and Women's Hospital
United States
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Lilley, Elizabeth J; Cooper, Zara; Schwarze, Margaret L et al. (2018) Palliative Care in Surgery: Defining the Research Priorities. Ann Surg 267:66-72
Hua, May; Scales, Damon C; Cooper, Zara et al. (2017) Impact of Public Reporting of 30-day Mortality on Timing of Death after Coronary Artery Bypass Graft Surgery. Anesthesiology 127:953-960