Letters
System, Boston, Massachusetts (Itani); Harvard Medical School, Boston, Massachusetts (Itani). Corresponding Author: Hillary J. Mull, PhD, MPP, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S Huntington Ave, 152M, Boston, MA 02130 ([email protected]). Published Online: September 24, 2014. doi:10.1001/jamasurg.2014.373. Author Contributions: Dr Mull had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Mull, Chen, Shwartz, Itani. Acquisition, analysis, or interpretation of data: Mull, Chen, Shwartz, Rosen. Drafting of the manuscript: Mull, Itani. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Mull, Chen, Shwartz. Obtained funding: Rosen Administrative, technical, or material support: Chen, Itani. Study supervision: Rosen.
Table 1. Top 5 Most Common Surgical Procedures Performed for CHAMPIONS Patients and the Average Length of Stay Associated With Each Procedure Surgical Procedure Colon resection (hemicolectomy, low anterior resection, sigmoidectomy)
Part of Total, %
Average Length of Stay, d
25
17.67
Lung resection (lobectomy, wedge resection)
18
6.77
Coronary artery bypass grafting
14
10.00
Open-heart valve replacement or repair
7
12.00
Cholecystectomy
7
4.00
Abbreviation: CHAMPIONS, Comprehensive Home-Based Acute Care Medical Program Initiative for Older Noncritical Surgical Patients.
Conflict of Interest Disclosures: None reported. Funding/Support: This research was funded by VA Health Services Research and Development Service grant SDR 07-002 (Dr Rosen, principal investigator). Role of the Funder/Sponsor: The VA Health Services Research and Development Service had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Previous Presentation: This paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 7, 2014; New Haven, Connecticut. 1. Khuri SF, Daley J, Henderson W, et al; National VA Surgical Quality Improvement Program. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg. 1998;228(4):491-507. 2. Bratzler DW. The Surgical Infection Prevention and Surgical Care Improvement Projects: promises and pitfalls. Am Surg. 2006;72(11):1010-1016. 3. Patient Safety Indicators overview. Agency for Healthcare Research and Quality website. http://www.qualityindicators.ahrq.gov/Modules/psi_overview.aspx. Accessed March 3, 2013. 4. Department of Veterans Affairs; Veterans Health Administration (VHA). 2010 VHA Facility Quality and Safety Report. http://www.va.gov/health/docs /HospitalReportCard2010.pdf. Published October 2010. Accessed August 13, 2014. 5. Agency for Healthcare Research and Quality (AHRQ). AHRQ Quality Indicators: Composite Measures User Guide for the Patient Safety Indicators (PSI), Version 4.2. Rockville, MD: AHRQ; 2010. 6. Feinstein AR. Multi-item “instruments” vs Virginia Apgar’s principles of clinimetrics. Arch Intern Med. 1999;159(2):125-128.
ASSOCIATION OF VA SURGEONS
Comprehensive Home-Based Acute Care Medical Program Initiative for Older Noncritical Surgical Patients Half of the people older than 65 years of age will undergo a surgical procedure in their remaining lifetime.1 With more than 1 million veterans currently older than 84 years of age, many compromised individuals will be seeking surgical care in Veterans Affairs (VA) hospitals.2 Postoperatively, discharge needs are often underestimated and complicated to coordinate. In 2010, the Departments of Surgery and Geriatrics at the VA Connecticut Healthcare System received VA Clinical Initiative funding to create the Comprehensive Home-Based Acute Care Medical Program Initiative for Older Noncritical Surgical Patients (CHAMPIONS), an individualized program intended to return geriatric patients home with maximum independence after surgery. 1212
Methods | The CHAMPIONS team consisted of a geriatrician, an advanced practice registered nurse, a physical therapist, a surgeon, and a case manager. Geriatric patients undergoing elective major surgery were eligible. Patients gave oral informed consent to participate in CHAMPIONS. There was no financial compensation given. Preoperative cognitive assessments (using the Saint Louis University Mental Status Examination score), functional assessments (using the activities of daily living score and the independent activities of daily living score), and home safety assessments were conducted by the advanced practice registered nurse and physical therapist during home visits to determine in-hospital and postdischarge needs, including dementia prevention tools and home safety equipment. Patients were comanaged during hospitalization, seen at home 48 to 72 hours after hospital discharge, and followed up for 30 days. Emergency department visits and 30-day readmissions were tracked. Using match-paired Wilcoxon tests, we reassessed patients 30 days after hospital discharge for change in cognition or function. Institutional review board approval was obtained before analyzing the CHAMPIONS database. Results | Seventy-two patients entered CHAMPIONS. Eight patients did not complete the program at the patient’s or patient’s family’s request, and only 6 required short-term rehabilitation; 58 patients were discharged home and completed the postdischarge evaluation. The median patient age was 79 years (range, 68-93 years). More than 87% of patients underwent general or cardiothoracic surgery (Table 1). Fifty-four percent had a cognitive deficit, and 35% were frail. There was no significant postoperative change in the Saint Louis University Mental Status Examination scores (for 55 patients; P = .92) or in activities of daily living scores (for 58 patients; P = .83). There was a small decrease in postoperative independent activities of daily living scores (for 58 patients; P = .03; maximum score, 16; preoperative median score, 16 [interquartile range, 14-16]; postoperative median score, 15 [interquartile range, 12-16]). Eighteen patients had emergency department visits within 30 days of hospital discharge, and only 8 of the 72 patients (11.1%) required readmission (Table 2). Discussion | The use of CHAMPIONS has improved geriatric surgical care at the West Haven VA hospital as demonstrated by
JAMA Surgery November 2014 Volume 149, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 05/28/2015
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Letters
Table 2. Reasons for Emergency Department Visita Readmission Required?
Reason(s)
a
Left shoulder pain secondary to metastatic cancer
Yes
Fall, dehydration, Clostridium difficile infection
Yes
Fall
Yes
Hyponatremia
Yes
Abdominal pain
Yes
Cellulitis
Yes
Small-bowel obstruction
Yes
Wound infection
Yes
Ostomy evaluation
No
Deep venous thrombosis
No
Nausea and vomiting
No
Obstructed Foley catheter
No
Low back pain
No
Constipation
No
Heartburn
No
Medication-induced hypotension
No
Percutaneous cholecystostomy tube evaluation
No
Vomiting and diarrhea
No
Demonstrating 18 emergency department visits and 8 readmissions within 30 days of hospital discharge.
patients safely returning home without a clinically significant change in cognitive or functional status. The program has allowed very frail patients, who had been safe at home prior to surgery, to return home after surgery. As Zenilman3 proposed in 2013, CHAMPIONS uses geriatric indicators, such as frailty scoring, preoperatively to anticipate patients’ needs before and after surgery. Indeed, many of the preoperative assessment parameters for CHAMPIONS are found in the “Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient” from the American College of Surgeons and American Geriatric Society.4 Tillou et al5 demonstrated that the use of geriatric consultation with trauma surgery patients improved outcomes. The positive outcomes of CHAMPIONS are credited to the comanagement of patients by the surgery and geriatrics teams. Beyond patient care, CHAMPIONS affords a care model within the VA healthcare system that can be used for education and research. During VA hospital rotations, Yale University surgery residents make rounds with the geriatric advanced practice registered nurse and get real-time feedback about how their care and medication choices may have different consequences for older patients than for younger adults; residents and students may join the advanced practice registered nurse and physical therapist on home visits to better understand patients’ needs. Lastly, as we have begun to demonstrate, CHAMPIONS, as a model of care, could be a rich source of outcomes data as we innovate health care delivery for geriatric patients.
CHAMPIONS is a promising model of multidisciplinary care using preoperative in-home assessment, perioperative comanagement, and postoperative follow-up to return compromised older veterans safely to their homes with maximum function following major surgery. John J. Tackett, MD Lisa M. Walke, MD Linda Accordino, MSN Emily Melin, MSN Troy Bishop Chandrika Kumar, MD, MBBS Ronnie A. Rosenthal, MD, MS Author Affiliations: Departments of Surgery and Geriatric Medicine, Yale University School of Medicine, New Haven, Connecticut (Tackett, Walke, Kumar, Rosenthal); VA Connecticut Healthcare System, West Haven, Connecticut (Tackett, Accordino, Melin, Bishop, Kumar, Rosenthal). Corresponding Author: Ronnie A. Rosenthal, MD, MS, Departments of Surgery and Geriatric Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Ave, West Haven, CT 06516 ([email protected]). Published Online: September 24, 2014. doi:10.1001/jamasurg.2014.1335. Author Contributions: Drs Rosenthal and Tackett had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tackett, Walke, Accordino, Melin, Rosenthal. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Tackett, Melin, Rosenthal. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Tackett, Accordino, Melin. Obtained funding: Walke, Accordino, Rosenthal. Administrative, technical, or material support: Accordino, Melin, Bishop, Rosenthal. Study supervision: Accordino, Kumar, Rosenthal. Conflict of Interest Disclosures: None reported. Previous Presentation: This paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 6, 2014; New Haven, Connecticut. 1. Rosenthal RA, Zenilman ME, Katlic MR, eds. Principles and Practice of Geriatric Surgery. New York, NY: Springer; 2011. 2. National Center for Veterans Analysis and Statistics. Veteran population. US Dept of Veterans Affairs website. http://www.va.gov/vetdata/Veteran_Population .asp. Accessed January 1, 2014. 3. Zenilman ME. Geriatric risk assessment in surgery: keeping it simple. JAMA Surg. 2013;148(12):1138-1139. 4. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; American College of Surgeons National Surgical Quality Improvement Program; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. 5. Tillou A, Kelley-Quon L, Burruss S, et al. Long-term postinjury functional recovery: outcomes of geriatric consultation. JAMA Surg. 2014;149(1):83-89.
CORRECTION Missing Subtitle: In the Special Communication titled “Summary of the Panel Session at the 38th Annual Surgical Symposium of the Association of VA Surgeons,” published online September 17, 2014 (doi:10.1001/jamasurg.2014.2064), the subtitle was missing. The subtitle “What Is the Big Deal About Frailty?” should be added. This article was corrected online.
jamasurgery.com
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Copyright 2014 American Medical Association. All rights reserved.
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1213
System, Boston, Massachusetts (Itani); Harvard Medical School, Boston, Massachusetts (Itani). Corresponding Author: Hillary J. Mull, PhD, MPP, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S Huntington Ave, 152M, Boston, MA 02130 ([email protected]). Published Online: September 24, 2014. doi:10.1001/jamasurg.2014.373. Author Contributions: Dr Mull had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Mull, Chen, Shwartz, Itani. Acquisition, analysis, or interpretation of data: Mull, Chen, Shwartz, Rosen. Drafting of the manuscript: Mull, Itani. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Mull, Chen, Shwartz. Obtained funding: Rosen Administrative, technical, or material support: Chen, Itani. Study supervision: Rosen.
Table 1. Top 5 Most Common Surgical Procedures Performed for CHAMPIONS Patients and the Average Length of Stay Associated With Each Procedure Surgical Procedure Colon resection (hemicolectomy, low anterior resection, sigmoidectomy)
Part of Total, %
Average Length of Stay, d
25
17.67
Lung resection (lobectomy, wedge resection)
18
6.77
Coronary artery bypass grafting
14
10.00
Open-heart valve replacement or repair
7
12.00
Cholecystectomy
7
4.00
Abbreviation: CHAMPIONS, Comprehensive Home-Based Acute Care Medical Program Initiative for Older Noncritical Surgical Patients.
Conflict of Interest Disclosures: None reported. Funding/Support: This research was funded by VA Health Services Research and Development Service grant SDR 07-002 (Dr Rosen, principal investigator). Role of the Funder/Sponsor: The VA Health Services Research and Development Service had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Previous Presentation: This paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 7, 2014; New Haven, Connecticut. 1. Khuri SF, Daley J, Henderson W, et al; National VA Surgical Quality Improvement Program. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg. 1998;228(4):491-507. 2. Bratzler DW. The Surgical Infection Prevention and Surgical Care Improvement Projects: promises and pitfalls. Am Surg. 2006;72(11):1010-1016. 3. Patient Safety Indicators overview. Agency for Healthcare Research and Quality website. http://www.qualityindicators.ahrq.gov/Modules/psi_overview.aspx. Accessed March 3, 2013. 4. Department of Veterans Affairs; Veterans Health Administration (VHA). 2010 VHA Facility Quality and Safety Report. http://www.va.gov/health/docs /HospitalReportCard2010.pdf. Published October 2010. Accessed August 13, 2014. 5. Agency for Healthcare Research and Quality (AHRQ). AHRQ Quality Indicators: Composite Measures User Guide for the Patient Safety Indicators (PSI), Version 4.2. Rockville, MD: AHRQ; 2010. 6. Feinstein AR. Multi-item “instruments” vs Virginia Apgar’s principles of clinimetrics. Arch Intern Med. 1999;159(2):125-128.
ASSOCIATION OF VA SURGEONS
Comprehensive Home-Based Acute Care Medical Program Initiative for Older Noncritical Surgical Patients Half of the people older than 65 years of age will undergo a surgical procedure in their remaining lifetime.1 With more than 1 million veterans currently older than 84 years of age, many compromised individuals will be seeking surgical care in Veterans Affairs (VA) hospitals.2 Postoperatively, discharge needs are often underestimated and complicated to coordinate. In 2010, the Departments of Surgery and Geriatrics at the VA Connecticut Healthcare System received VA Clinical Initiative funding to create the Comprehensive Home-Based Acute Care Medical Program Initiative for Older Noncritical Surgical Patients (CHAMPIONS), an individualized program intended to return geriatric patients home with maximum independence after surgery. 1212
Methods | The CHAMPIONS team consisted of a geriatrician, an advanced practice registered nurse, a physical therapist, a surgeon, and a case manager. Geriatric patients undergoing elective major surgery were eligible. Patients gave oral informed consent to participate in CHAMPIONS. There was no financial compensation given. Preoperative cognitive assessments (using the Saint Louis University Mental Status Examination score), functional assessments (using the activities of daily living score and the independent activities of daily living score), and home safety assessments were conducted by the advanced practice registered nurse and physical therapist during home visits to determine in-hospital and postdischarge needs, including dementia prevention tools and home safety equipment. Patients were comanaged during hospitalization, seen at home 48 to 72 hours after hospital discharge, and followed up for 30 days. Emergency department visits and 30-day readmissions were tracked. Using match-paired Wilcoxon tests, we reassessed patients 30 days after hospital discharge for change in cognition or function. Institutional review board approval was obtained before analyzing the CHAMPIONS database. Results | Seventy-two patients entered CHAMPIONS. Eight patients did not complete the program at the patient’s or patient’s family’s request, and only 6 required short-term rehabilitation; 58 patients were discharged home and completed the postdischarge evaluation. The median patient age was 79 years (range, 68-93 years). More than 87% of patients underwent general or cardiothoracic surgery (Table 1). Fifty-four percent had a cognitive deficit, and 35% were frail. There was no significant postoperative change in the Saint Louis University Mental Status Examination scores (for 55 patients; P = .92) or in activities of daily living scores (for 58 patients; P = .83). There was a small decrease in postoperative independent activities of daily living scores (for 58 patients; P = .03; maximum score, 16; preoperative median score, 16 [interquartile range, 14-16]; postoperative median score, 15 [interquartile range, 12-16]). Eighteen patients had emergency department visits within 30 days of hospital discharge, and only 8 of the 72 patients (11.1%) required readmission (Table 2). Discussion | The use of CHAMPIONS has improved geriatric surgical care at the West Haven VA hospital as demonstrated by
JAMA Surgery November 2014 Volume 149, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 05/28/2015
jamasurgery.com
Letters
Table 2. Reasons for Emergency Department Visita Readmission Required?
Reason(s)
a
Left shoulder pain secondary to metastatic cancer
Yes
Fall, dehydration, Clostridium difficile infection
Yes
Fall
Yes
Hyponatremia
Yes
Abdominal pain
Yes
Cellulitis
Yes
Small-bowel obstruction
Yes
Wound infection
Yes
Ostomy evaluation
No
Deep venous thrombosis
No
Nausea and vomiting
No
Obstructed Foley catheter
No
Low back pain
No
Constipation
No
Heartburn
No
Medication-induced hypotension
No
Percutaneous cholecystostomy tube evaluation
No
Vomiting and diarrhea
No
Demonstrating 18 emergency department visits and 8 readmissions within 30 days of hospital discharge.
patients safely returning home without a clinically significant change in cognitive or functional status. The program has allowed very frail patients, who had been safe at home prior to surgery, to return home after surgery. As Zenilman3 proposed in 2013, CHAMPIONS uses geriatric indicators, such as frailty scoring, preoperatively to anticipate patients’ needs before and after surgery. Indeed, many of the preoperative assessment parameters for CHAMPIONS are found in the “Checklist for the Optimal Preoperative Assessment of the Geriatric Surgical Patient” from the American College of Surgeons and American Geriatric Society.4 Tillou et al5 demonstrated that the use of geriatric consultation with trauma surgery patients improved outcomes. The positive outcomes of CHAMPIONS are credited to the comanagement of patients by the surgery and geriatrics teams. Beyond patient care, CHAMPIONS affords a care model within the VA healthcare system that can be used for education and research. During VA hospital rotations, Yale University surgery residents make rounds with the geriatric advanced practice registered nurse and get real-time feedback about how their care and medication choices may have different consequences for older patients than for younger adults; residents and students may join the advanced practice registered nurse and physical therapist on home visits to better understand patients’ needs. Lastly, as we have begun to demonstrate, CHAMPIONS, as a model of care, could be a rich source of outcomes data as we innovate health care delivery for geriatric patients.
CHAMPIONS is a promising model of multidisciplinary care using preoperative in-home assessment, perioperative comanagement, and postoperative follow-up to return compromised older veterans safely to their homes with maximum function following major surgery. John J. Tackett, MD Lisa M. Walke, MD Linda Accordino, MSN Emily Melin, MSN Troy Bishop Chandrika Kumar, MD, MBBS Ronnie A. Rosenthal, MD, MS Author Affiliations: Departments of Surgery and Geriatric Medicine, Yale University School of Medicine, New Haven, Connecticut (Tackett, Walke, Kumar, Rosenthal); VA Connecticut Healthcare System, West Haven, Connecticut (Tackett, Accordino, Melin, Bishop, Kumar, Rosenthal). Corresponding Author: Ronnie A. Rosenthal, MD, MS, Departments of Surgery and Geriatric Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Ave, West Haven, CT 06516 ([email protected]). Published Online: September 24, 2014. doi:10.1001/jamasurg.2014.1335. Author Contributions: Drs Rosenthal and Tackett had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tackett, Walke, Accordino, Melin, Rosenthal. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Tackett, Melin, Rosenthal. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Tackett, Accordino, Melin. Obtained funding: Walke, Accordino, Rosenthal. Administrative, technical, or material support: Accordino, Melin, Bishop, Rosenthal. Study supervision: Accordino, Kumar, Rosenthal. Conflict of Interest Disclosures: None reported. Previous Presentation: This paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 6, 2014; New Haven, Connecticut. 1. Rosenthal RA, Zenilman ME, Katlic MR, eds. Principles and Practice of Geriatric Surgery. New York, NY: Springer; 2011. 2. National Center for Veterans Analysis and Statistics. Veteran population. US Dept of Veterans Affairs website. http://www.va.gov/vetdata/Veteran_Population .asp. Accessed January 1, 2014. 3. Zenilman ME. Geriatric risk assessment in surgery: keeping it simple. JAMA Surg. 2013;148(12):1138-1139. 4. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; American College of Surgeons National Surgical Quality Improvement Program; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. 5. Tillou A, Kelley-Quon L, Burruss S, et al. Long-term postinjury functional recovery: outcomes of geriatric consultation. JAMA Surg. 2014;149(1):83-89.
CORRECTION Missing Subtitle: In the Special Communication titled “Summary of the Panel Session at the 38th Annual Surgical Symposium of the Association of VA Surgeons,” published online September 17, 2014 (doi:10.1001/jamasurg.2014.2064), the subtitle was missing. The subtitle “What Is the Big Deal About Frailty?” should be added. This article was corrected online.
jamasurgery.com
JAMA Surgery November 2014 Volume 149, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 05/28/2015
1213
