title: Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients.
abstract: BACKGROUND
  older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation.
  
  
  OBJECTIVE
  to design, embed, and evaluate an evidence-based comprehensive geriatric assessment (CGA) service for at-risk older patients undergoing elective surgery.
  
  
  METHODS
  urban teaching hospital.
  
  
  METHODS
  elective surgical patients aged 65+.
  
  
  METHODS
  multidisciplinary preoperative CGA service with post-operative follow-through (proactive care of older people undergoing surgery ['POPS']).
  
  
  METHODS
  observational cohort study and multilevel surveys (development and modelling phase). Prospective 'before and after' comparison (exploratory evaluation).
  
  
  RESULTS
  findings from the development phase showed high levels of preoperative co-morbidity, no multidisciplinary preoperative input, and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients. Comparison of 2 cohorts of elective orthopaedic patients (pre-POPS vs POPS, N = 54) showed the POPS group had fewer post-operative medical complications including pneumonia (20% vs 4% [p = 0.008]) and delirium (19% vs 6% [p = 0.036]), and significant improvements in areas reflecting multidisciplinary practice including pressure sores (19% vs 4% [p = 0.028]), poor pain control (30% vs 2% [p<0.001]), delayed mobilisation (28% vs 9% [p = 0.012]) and inappropriate catheter use (20% vs 7% [p = 0.046]). Length of stay was reduced by 4.5 days. There were fewer delayed discharges relating to medical complications (37% vs 13%) or waits for OT assessment or equipment (20% vs 4%).
  
  
  CONCLUSIONS
  a proactive evidence-based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions. Pre/post comparison in elective orthopaedic patients showed improved (within methodological limitations) post-operative outcomes indicative of better clinical effectiveness and efficiency, and contributed to the service obtaining mainstream funding. Informed by the present study, a randomised controlled trial is ongoing.
authors.affiliation: Department of Ageing and Health, St. Thomas' Hospital, 9th Floor, North Wing, Lambeth Palace Road, London SE1 7EH, UK. danielle.harari@kcl.ac.uk
authors.forename: Danielle
authors.initials: D
authors.lastname: Harari
authors.forename: Adrian
authors.initials: A
authors.lastname: Hopper
authors.forename: Jugdeep
authors.initials: J
authors.lastname: Dhesi
authors.forename: Gordana
authors.initials: G
authors.lastname: Babic-Illman
authors.forename: Linda
authors.initials: L
authors.lastname: Lockwood
authors.forename: Finbarr
authors.initials: F
authors.lastname: Martin
mesh_terms: D000368:Aged; D017558:Elective Surgical Procedures; D005260:Female; D015577:Geriatric Assessment; D006304:Health Status; D006801:Humans; D007902:Length of Stay; D008297:Male; D011183:Postoperative Complications; D011300:Preoperative Care