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.