title: Surgical palliative care consultations over time in relationship to systemwide frailty screening.
abstract: OBJECTIVE
  The need for integrating palliative care into surgical services has been established within the surgical literature. The ability to effectively screen, obtain an appropriately timed consultation, and determine the effect of consultation remains problematic.
  
  
  OBJECTIVE
  To examine surgical palliative care consultations over time and their relationship to the initiation and implementation of a systemwide frailty-screening program.
  
  
  METHODS
  We reviewed all surgical palliative care consultations performed between January 1, 2006, and August 31, 2013, and abstracted the referring service (medicine/surgery), date of surgery (if any), date of death (if any), and all variables required to calculate a frailty score using the risk analysis index. We examined changes in mortality and referral patterns before and after implementation of the frailty-screening program using multivariable logistic regression.
  
  
  METHODS
  Surgical palliative care consultations, including frailty screening.
  
  
  METHODS
  The primary study outcomes were 30-, 180-, and 360-day mortality.
  
  
  RESULTS
  From 2006 to 2013, a total of 310 palliative care consultations were ordered for surgical patients: 160 before initiation of frailty screening (January 1, 2011) and 150 after initiation of the program. The groups had similar demographics, comorbidities, and frailty scores. After initiation, we observed dramatically decreased mortality at 30, 180, and 360 days (21.3% vs 31.9%, 44.0% vs 70.6%, and 66.0% vs 78.8%, respectively; all P < .05). This coincided with an increased rate of palliative care consultations from 32 per year to 56 per year. After initiation of the program, consultations were more likely to be requested by surgeons (56.7% vs 24.4%; P < .05) and were more likely to occur before the index operation (52.0% vs 26.3%; P < .05). Implementation of the screening program was associated with a 33% reduction in 180-day mortality (odds ratio [OR], 0.37; 95% CI, 0.22-0.62; P < .001) even after controlling for age, frailty, and whether the patients had surgery. Modeled mortality was also reduced when the palliative care consultation was ordered by a surgeon (OR, 0.50; CI, 0.30-0.83; P = .007) or ordered before the operation (OR, 0.52; CI, 0.30-0.90; P = .02).
  
  
  CONCLUSIONS
  Our data suggest that a systematic frailty-screening program effectively identifies at-risk surgical patients and is associated with a significant reduction in mortality for patients undergoing palliative care consultation. Analysis also suggests that preoperative palliative care consultations ordered by surgeons are associated with reduced mortality rates.
authors.affiliation: College of Medicine, University of Nebraska Medical Center, Omaha.
authors.forename: Katherine F
authors.initials: KF
authors.lastname: Ernst
authors.affiliation: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Hall
authors.affiliation: College of Public Health Masters Programs, Department of Biostatistics, University of Nebraska Medical Center, Omaha.
authors.forename: Kendra K
authors.initials: KK
authors.lastname: Schmid
authors.affiliation: Department of Surgery, Nebraska Western Iowa Veterans Affairs Medical Center, Omaha.
authors.forename: Georgia
authors.initials: G
authors.lastname: Seever
authors.affiliation: Department of Surgery, Nebraska Western Iowa Veterans Affairs Medical Center, Omaha.
authors.forename: Pierre
authors.initials: P
authors.lastname: Lavedan
authors.affiliation: Veterans Health Administration, Deputy Undersecretary of Health for Clinical Operations and Management, Washington, DC.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Lynch
authors.affiliation: Department of Surgery, Nebraska Western Iowa Veterans Affairs Medical Center, Omaha6Department of Surgery, University of Nebraska Medical Center, Omaha.
authors.forename: Jason Michael
authors.initials: JM
authors.lastname: Johanning
mesh_terms: D000368:Aged; D019033:Delivery of Health Care, Integrated / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D016017:Odds Ratio; D010166:Palliative Care / Q000706:statistics & numerical data*; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000401:mortality*; D058996:Quality Improvement / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D018570:Risk Assessment; D015996:Survival Rate; D014481:United States