Clinically Meaningful Outcome Measures: A Role for Geriatric Assessment

The authors in the accompanying article employ function-based geriatric assessment in the pre- and postoperative evaluation of older adults. Traditionally, “preoperative risk assessment” refers to cardiac, pulmonary, or infectious risk, with mortality (for good reason) as the primary measure of surgical outcome. In geriatric patients, this approach often misses important aspects of the patient’s condition (eg, functional dependence) that are relevant not only for care teams as they make treatment plans but also for patients as they anticipate what their course of treatment might look like. Ongoing emphasis on more comprehensive assessment—including functional status—will help to refine the evaluation of geriatric patients across disciplines and could improve conversations with patients and families regarding their care.

For both patients and their families, good recovery is closely linked with function. In studies from various surgical disciplines, poor postoperative functional status has been associated with lower quality-of-life scores¹ for patients, as well as increased burden for their caregivers.² Functional recovery also has important implications from a systems-based perspective, because postoperative functional deficits have also been associated with increased healthcare utilization and costs.³

In recent years, geriatric assessment that is more comprehensive in scope has gained attention as part of preoperative evaluation^4,5 and pretreatment evaluation of oncology patients more broadly,^6,7 and it can be easily incorporated without abandoning more traditional outcome measures. For example, poor preoperative functional status has been associated with increased postoperative morbidity and mortality,^8,9 higher rates of perioperative complications,^10,11 increased length of stay,¹² and discharge to a nonhome setting.¹³ Many researchers have also begun to explore “prehabilitation”—therapy aimed at enhancement of functional status before surgery—as an approach that might improve these outcomes.^14-16

Fewer studies include functional status (eg, activities of daily living [ADL] dependence) among their postoperative measures; however, available results have yielded useful insights. In recent studies of older surgery patients,¹⁷ including oncologic surgery patients,¹⁸ higher scores from a preoperative geriatric assessment tool that included functional status, mood, cognition, and mobility were associated with increased probability of both geriatric and surgical complications, increased length of stay, and increased postdischarge needs, including new functional dependence. Of note, the tool employed was able to be administered in a clinic setting in less than 10 minutes.

Creating a shared understanding of likely outcomes—including less traditional outcomes such as functional status—among providers, patients, and families is an important part of surgical planning.

The accompanying article evaluated patients’ functional status at 3 time points: preoperatively, at postoperative day 8, and 12 months after hospital discharge. This approach adds clarity to what patients can expect in their postoperative course and would provide useful information for providers to reference in approaching shared decision-making. Also of note is the significant correlation between ADL status and lethality in the distal urinary tract surgery group, particularly given that ADL assessment requires little more than completion of a questionnaire.

As the population ages and becomes more comorbid, performing thorough but efficient preoperative assessment will become increasingly critical. Moreover, these higher-
complexity patients will require more nuanced conversations regarding potential risks and benefits of treatments. Incorporating more comprehensive geriatric assessment and focusing on practical, functional measures will aid providers not only in preparing to care for their patients but in setting realistic expectations for patients and families. Future research should include such measures not only preoperatively, but throughout the postoperative timeline.

Kovar is an internist who specializes in geriatrics at the University of Nebraska Medical Center.

Teply is an internist at the University of Nebraska Medical Center. She is Board Certified in Hospice and Palliative Medicine.

References

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