Introduction
The proportion of older people undergoing surgery is increasing faster than the rate of population ageing1-2. This is representative of advances in surgical and anaesthetic techniques. However, it is well established that this patient group are more susceptible to adverse outcomes2-3. Complications in the perioperative period are typically medical and are closely linked to geriatric syndromes including frailty, sarcopenia and cognitive deficits. Collaborative, multidisciplinary models of care including proactive identification of the most pertinent risk factors may allow targeted intervention to minimise perioperative morbidity and mortality.
Older people undergoing vascular surgery are a particularly vulnerable, high-risk group. This frequently reflects the presence of multiple comorbidities including hypertension, diabetes, ischaemic heart disease and additional lifestyle risk factors such as smoking. In particular, the incidence and prevalence of peripheral vascular disease increases with age; complex bypass surgery therefore forms a significant proportion of work in arterial centres4.
Decision-making with regards to patient selection for surgical intervention is challenging. Advances in endovascular surgery in the modern era have rendered some types of surgery less physiologically challenging. Societal attitudes and expectations have also evolved. Determining which patients are likely to benefit most from intervention, and in whom the elevated risk profile is acceptable is complex. Decisions have historically been made on the basis of age alone as a proxy for frailty and comorbidity5. Despite an elevated risk profile, older patients can have good outcomes from vascular surgery. However, limited data have been reported describing outcomes for matched patients not undergoing surgery. The natural history of vascular disease at advanced age is therefore somewhat less clear6. Recognition of patients nearing the end of their life and utilising effective palliative care is important in these scenarios, although in many cases surgery has an important palliative symptomatic role7-8. Nonetheless, the postoperative period is often protracted in older patients and syndromes such as delirium commonly lead to functional decline and increased dependency. The provision of proactive multidisciplinary team working ensures that surgical intervention can be provided to those for whom quality of life and independence can be restored, whilst balancing the risks and benefits of surgery and ensuring an opportunity for risk factor modification and optimisation.
Perioperative Comprehensive Geriatric Assessment (CGA) utilised in the context of older patients undergoing vascular surgery has been shown to reduce length of stay (LOS)9-10. Replicating aspects of the CGA service evaluated in the randomised control trial conducted (RCT) by Partridge et al, we aimed to assess the impact of daily provision of senior-led medical liaison provided for patients aged 65 years and older admitted to our regional tertiary vascular centre. Prior to the introduction of this service development, ad hoc reactive review was provided on demand by the duty medical registrar. Our primary outcome measure was reduction in LOS. Our secondary outcome measure was reduction in the number of postoperative complications. We also aimed to determine the impact of age on our primary and secondary outcome measures.