The Role of Comprehensive Geriatric Assessment and Shared Decision Making in patients being considered for Orthopaedic Surgery
Abstract
Introduction
Our perioperative service for older people undergoing surgery (POPS) commenced preoperative assessment of co-morbid and frail patients undergoing elective orthopaedic surgery in 2021. As part of the comprehensive geriatric assessment (CGA) and shared-decision-making process (SDM), we wanted to analyse the decisions our patients made around surgery and how many regretted having surgery.
Methods
- Review of all orthopaedic patients seen by POPS between September 2021-December 2022
Intervention
- CGA and SDM on all patients
- Data collected: comorbidities, Clinical Frailty Scale (CFS), SDM outcome.
- Decision regret scale was sent out 6 months post op from August 2022.
Results
- 111 patients assessed. Median age 89 (range 60-97). Median CFS 4 (range 1-7)
- Median comorbidities 12 (range 2-22).
- Surgery considered: knee 43%, hip 33%, shoulder 10%, spine 6%, revision hip 5%, and revision knee 3%.
- 77% wanted to proceed with surgery and 13% did not after SDM. 5% were deemed not fit enough and 5% are still awaiting final decision outcomes.
- Decision regret data has been returned by 10/14 (71%) of patients who proceeded. None regretted their decision.
Conclusion
The majority of patients seen by POPS wish to proceed with orthopaedic surgery. However, 13% did not wish to proceed following SDM which is similar to the 14% of patients who regretted undergoing surgery in other settings1. Of those that have returned the 6-month post op questionnaires, none have regretted their decision. Understanding how optimisation and appropriate SDM impacts on the patient experience is important as frailty impacts adversely on patient reported outcomes in elective hip and knee surgery. Frail patients are also less likely to report their postoperative outcomes in national data sets compared to less frail patients2.
- CPOC website
- Cook et al (2022). The impact of frailty on patient reported outcomes following hip and knee arthroplasty. Age and Ageing.
Comments
Interesting 13% decided not to proceed
Avoiding decisional regret is very important as it has significant cost to the patient and the NHS. It's fantastic that SDM can avoid/ decrease this very adverse event and should almost certainly be part of the surgical consultation, as well as being a component of the POPS clinical assessment (in addition to the patient optimisation). It would be interesting to see what portion of patients feel they have SDM without a POPS review, and what information they feel would be helpful in order to enable SDM in this setting.