Frailty, Optimisation and Shared Decision-Making: Evaluation of an Orthogeriatric Preoperative Clinic for Older Patients

The Orthogeriatric pre-operative assessment clinic was established in 2021 at the Nuffield Orthopaedic Centre, Oxford, to support frail older adults being considered for elective orthopaedic procedures, including complex revision surgery. We evaluated outcomes for 50 consecutive patients assessed by the service.

We interrogated the notes of 50 patients seen looking at demographics (including age and frailty), comorbidities, origin of referrals, wait times, issues identified in clinic, operation type, post-operative outcomes and mortality.

The average wait time for a clinic review was 2.5 weeks, with 96% of patients’ being seen within 4 weeks of referral. Reasons for referral were varied and multiple, including frailty (40%), multiple comorbidities (20%) and cognitive concerns (18%). Average age was 81. Patients were frail with 76% having a CFS of 5 or more. Patients were complex with high levels of comorbidities. 72% had new medical issues identified in clinic, 26% required iron replacement, and 22% required onward referrals. 16% made a decision not to proceed to surgery following discussions. Only 2 patients had a same day cancellation, both due to new medical issues that had developed since review. 34% of patients had a post-operative complication. Only 1 required readmission. At the point of auditing 19 of the 50 patients had died - 8 had not undergone the operation. Of those who died post-operatively, 1 died of a complication related to the operative admission with others dying from subsequent illnesses. 

This orthogeriatric service provides timely assessment and optimisation of frail, multimorbid older adults undergoing elective orthopaedic surgery. The clinic identifies previously unrecognised medical issues, facilitates informed shared decision-making and supports low rates of cancellation and readmission within a high-risk population. The longer-term mortality observed highlights the advanced frailty of this cohort and reinforces the importance of patient selection and discussions regarding prognosis and the goals of surgery.