Discussion
This study has demonstrated beneficial effects resulting from routine,
proactive, senior-led medical liaison to older multimorbid patients
admitted under vascular surgery. Firstly, there was an overall trend
reduction in LOS of 2.8 days with a significant reduction (7.84 days) in
LOS for patients admitted for more than seven days. For patients
admitted longer than seven days, 30-day readmission rates reduced by
8.9%. Secondly, there was a trend reduction in complication frequency
following service implementation with significant reductions seen for
patients admitted acutely. This may indicate that patients who gain most
from such a service are those admittedly acutely, and those who sustain
a long length of stay. Long length of stay is typically associated with
complexity and complications, and it therefore plausible that medical
liaison may be of most value in this patient group.
These findings, also mirrored in similar studies assessing the impact of
geriatric liaison in orthopaedic, urological and gastrointestinal
surgery, may reflect prompt recognition and management of postoperative
complications and a proactive approach to postoperative goal-setting and
discharge planning9,11,15. As Partridge et al
established in their randomised control trial concerning patients
scheduled for vascular surgery, CGA can provide an opportunity to
recognise previously undiagnosed pathology across several domains
including delirium and comorbidity10.
This study included all patients aged 65 years and older admitted for
one or more nights; this enhances the generalisability of our results.
Few demographic differences were seen between the pre-intervention and
post-intervention groups and none reached statistical significance.
Notably, the potential benefits of length of stay reduction were not
offset by increased readmission rates.
However, there are important limitations. These include the study design
being retrospective and single centre with a focus on service
development where there was reliance on the quality of clinical records
to capture clinical details. To minimise this latter point, electronic
records such as discharge letters were cross-referenced with the
clinical notes to enhance accuracy. It was noted that discharge letters
did not often comprehensively summarise key medical issues. Another
limitation was that the service was delivered during normal working
hours (0800-1700, Monday to Friday) and therefore results must be
interpreted with the understanding that outside of these hours, a
reactive method was adopted which was reliant on acute services such as
the medical registrar.
In conclusion, these data indicate that existing RCT results
demonstrating the benefits of proactive medical liaison for complex
older patients undergoing vascular surgery may be reproduced in a
service development setting and can generate reductions in length of
stay, complication frequency and readmission rates in selected patients.
These effects reached statistical significance in patients admitted
acutely and in those with longer lengths of stay. These clinical and
economic advantages, which have previously been described in other
surgical settings, indicate that long-term investment in medical liaison
for complex patients admitted under vascular surgery may be
justified11. This study has informed sustainability of
the service and a model to be translated to other surgical specialities
(recognising capacity-building as a priority). Further research to
establish the wider-reaching effects such as provision of educational
support to junior surgical doctors and the benefits of tri-directional
learning amongst surgeons, anaesthetists and physicians would be useful
to enable further care processes and services to evolve.