Impact of a Care Pathway for Older Patients Undergoing Emergency Abdominal Surgery: A Before-and-After Study.

backgroundOlder patients undergoing emergency abdominal surgery face high risks of mortality and complications.

objectiveInvestigate whether a care pathway designed for older patients improves surgical outcomes.

methodsThis single-centre study investigated the effect of a care pathway for older patients undergoing emergency abdominal surgery, including preoperative frailty assessment, optimised perioperative care, and structured decision-making for severely frail patients. Following implementation of the pathway, patients aged ≥ 75 years were prospectively enrolled in the 'after' cohort (1 January 2020-16 April 2021) and compared with a historical 'before' cohort of patients (1 January 2016-31 December 2017). The primary outcome was the Comprehensive Complication Index (CCI), a composite measure encompassing 30-day mortality and postoperative complications. Secondary outcomes included 30-day postoperative mortality, the number of palliative patients, mortality at 1 and 3 years and postoperative complications.

resultsAmong 154 patients in the 'after' cohort (median age 82 years [Q1-Q3: 78-86], 54% women, 53% frail), the primary outcome did not differ significantly from that of the 170 patients in the 'before' cohort (CCI mean [95% CI]: 44 [39-48] vs. 50 [46-55]; p = 0.15). Postoperative 30-day mortality was significantly reduced (22% vs. 13%, p = 0.04). During the intervention, severely frail patients triaged to palliation (n = 12) were excluded from the study and received palliative care. High postoperative mortality was observed at 1 (31%) and 3 years (49%). Pulmonary (44% vs. 69%, p < 0.001) and gastrointestinal complications (39% vs. 52%; p = 0.02) were significantly reduced.

conclusionIn this 'before-and-after' study a care pathway designed for older patients undergoing emergency abdominal surgery had no significant impact on the composite outcome of postoperative mortality and complications. Postoperative 30-day mortality, pulmonary and gastrointestinal complications were significantly reduced, while long-term mortality remained high. Although the results should be interpreted with caution, they highlight the importance of careful preoperative evaluation. In this study, outcomes of elderly patients undergoing emergency abdominal surgery were compared before and after implementation of a care pathway for elderly patients in a moderately sized single centre. Overall it is noted that implementation of this care pathway resulted in a decision to offer palliation instead of surgery to several patients. While the primary outcome of comprehensive complication index did not differ between the before-and after groups, several secondary outcomes were improved in the after group. It should be noted however that multiple confounders could explain the difference, including selection bias of a more robust population offered surgery. The one-and three year mortality of both groups was very high, stressing the importance of a careful and critical assessment of preoperative comorbidity and frailty, as well as the importance of ensuring that the treatment offered aligns with the overall goals of care for the individual patient.