Analysis: Improving surgical care by engaging older adults in shared decision-making

• Kaiser Health News is reporting the American College of Surgeons has endorsed new standards of surgical care for older adults.
• Engaging patients of all ages in shared decision-making discussions has been shown to improve outcomes.
• The ACS’s Geriatric Surgery Verification Program is a step in the right direction given that conversations about shared decision-making or advanced directives don’t happen as frequently as they should.

Kaiser Health News is reporting in an Aug. 1 article “The Talk Seniors Need To Have With Doctors Before Surgery” that the American College of Surgeons has endorsed new standards. The standards include:

• Providing older adults with the opportunity to discuss their health goals and expectations for recovery preoperatively with their surgeon.
• Surgeons reviewing a patient’s advance directive or offering to help the patient complete one.
• Surgeons clearly identifying if a stay in an ICU is likely post-operatively. If it is, there needs to be a discussion related to the patient’s wishes on issues ranging from feeding tubes to mechanical ventilation to cardiac resuscitation.

Takeaway

Despite the well-documented improvements in patient experience of care, outcomes and reduction in the total cost of care, engaging the patient in shared decision-making or advanced directives discussions doesn’t happen as frequently as it should. So, the ACS’s Geriatric Surgery Verification Program is a step in the right direction. 

Decision aid improves patient experience of care: A 2012 study published in Health Affairs reports that patients who use decision aids:

• Report feeling more engaged in their care process.
• Experience reduced uncertainty about the decision.
• Have more realistic expectations for outcomes.

The Health Affairs study found that beyond improvements in patient experience of care, 25% of patients who use the decision-aid tools elect not to have surgery.

Making end-of-life choices known in advance improves outcomes: Having a documented advanced directive has been shown to improve the quality of care for both decedents and their survivors across a range of factors. Those factors include:

• The quality of death, as reported by next-of-kin, is higher for decedents who die at home or in hospice care, as outlined in an abstract in PubMed.gov of a July 24, 2002 Journal of Pain and Symptom Management article.
• It also reduces the detrimental impact to physical and mental health that caregivers experience following deaths characterized by use of aggressive end-of-life care.
• It reduces the likelihood that surviving spouses will die shortly thereafter, according to a 2008 JAMA Network article.

Should CMS consider a similar quality measure? Although I’m not sure the Centers for Medicare and Medicaid Services needs to pile another quality measure into Merit-based Incentive Payments or the Bundled Payments for Care Improvement Advanced programs, something around adherence to the ACS guidelines might make sense.