Understanding
perioperative mortality of
the elderly
Leona Wilson,
Chair POMRC
Summary
• Define elderly (for search terms)
• Describe their perioperative mortality
• (describe POMRC)
What is elderly?
Not defined, but
• Older than the doctor?
• Ages at which complication rates increase?
• Ages at which mortality rates increase?
– Earlier acute (40s) than elective admissions (60s)
– Second point of increase (80s)
– Trauma patients (37, 60, 78)
Shakespeare: As you like it
(all the worlds a stage)
• The sixth age shifts
Into the lean and slippered pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank, and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound.
• Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
Elderly?
• UN: 60+
– (WHO 50+ for Africa)
– new roles, loss of previous roles, or inability to make active
contributions to society.
• Retirement age: (OECD) (55)/60-65/67+
• Stages:
–
–
–
–
young, 60s
middle, 70s
Very, 80+
Very very: inactive, unhealthy, unproductive, and
ultimately unsuccessful ageing
Elderly?
(NZ) Perioperative Mortality Review
Committee
• POMRC is:
– Statutory, within HQSC
– Multidisciplinary
– Has a whole patient focus, also systems issues
– Is meant to support local QI processes
• NZPHD Act 2000 (legal powers):
– Confidentiality
– Require data submission
• Sister committees:
– CYMRC
– PMMRC
– FVDRC
– (SUMRC)
– Māori caucus
POMRC people
•
•
•
•
Patients, families and clinicians
Committee:
– Cathy Ferguson, Deputy Chair, ENT surgeon, RACS Councilor
– Michal Kluger, anaesthetist / pain medicine physician
– Jonathan Koea, GI Surgeon
– Teena Robinson, perioperative nurse
– Tony Williams, Intensivist
– Keri Parata-Pearse, nurse manager (quality)
– Rob Vigor-Brown, community (lawyer)
– Ian Civil, surgeon
HQSC
– Board,
• Chair Alan Merry
• Chair Mortality Review Committees Dale Bramley
– Mortality Unit: Shelley, Owen, Clifton, Dez
Phil Hider, University of Otago (epidemiological analyses)
Who died?
(Epidemiology of perioperative deaths)
• Uses real NZ information
• National minimum dataset and national mortality collection
• Investigate deaths related to specific procedures, patient and
complication
– Informed consent -> patient choice
• Track common procedures year by year
– Provide international comparisons to ‘benchmark’ NZ
• Report on perioperative mortality to WHO
• The future, investigating:
– Standardised mortality rates
– Risk calculator based on NZ data.
Limitations of current data:
(National minimum dataset)
From coded discharge summaries
• All publicly funded discharges,
• Significant proportion of private discharges
• (some private hospitals missing)
Proportion missing assessed via comparison with Joint Registry
• No significant difference in periop mortality in 2 sources
• Approximately 20% primary hips and knees missing from NMDS
Examples of POMRC data
What is the 30-day all-cause post-op mortality for 80+
year old patients having an acute cholecystectomy?
a.
b.
c.
d.
0.01% - 0.09%
0.1% - 0.9%
1% - 9%
10% +
Results
What is the 30-day all-cause post-op mortality for 80+ year
old patients having an acute colo-rectal resection?
a.
b.
c.
d.
0.01% - 0.09%
0.1% - 0.9%
1% - 9%
10% +
Results
What is the 30-day all-cause post-op mortality for 80+ year
old patients having an elective cataract extraction?
a.
b.
c.
d.
0.01% - 0.09%
0.1% - 0.9%
1% - 9%
10% +
Results
What is the 30-day all-cause post-op mortality for 80+ year
old patients having an elective knee replacement?
a.
b.
c.
d.
0.01% - 0.09%
0.1% - 0.9%
1% - 9%
10% +
Results
Poll: match 30-day all-cause mortality
for 80+ years patients
Rate
Procedure
Answer
a. 0.01% - 0.09%
Elective hip
replacement
B: 0.7%
b. 0.1%-0.9%
Acute colo-rectal
resection
D: 16.0%
c. 1% - 9%
Elective cataract
extraction
B: 0.25%
d. 10% +
Acute
cholecystectomy
C: 5.14%
Colorectal resection, acute
30 day mortality –
9.8%
Age:
ASA:
45-64 = 3.98%
1-2 = 3.16%
65-79 = 9.46%
3
= 9.69%
80+
4
= 26.2%
5
= 41.7%
= 19%
Inc. NZDep deciles 910
Who are the elderly? /%
80+
All patients
Acute
Elective
Acute
Elective
Pakehā
93
92
70
74
Māori
1.8
1.4
20
12
Female
67
49
57
53
NZ dep
1&2
16
15
15
19
NZ dep
9&10
18
16
28
21
Who are the elderly?
• Mainly pakehā (age distributions 2013 census)
Who are the elderly?/%
80+
Acute
Elective
All
patients
Acute
Elective
ASA
1&2
24
47
77
83
ASA 3
56
49
15
15
ASA 4
18
4
5
1
ASA 5
1
-
2
-
What procedures do 80+ undergo?
Acute
Elective
28% Those for # femur
11% Hip replacement
15% Hemiarthroplasty femur
9% Knee replacement
4% Hip replacement
8% Excision skin and subcut tissue
2% Debridement skin + tissue
6% TURP
2% Division abd. adhesions
5% Inguinal hernia repair
What is underlying cause of death for 80+
Acute
Elective
20% Falls
30% Malignancies
20% MI/other ischaemic heart
disease
24% MI/other ischaemic heart
disease
16% Other cardiovascular causes
18% Other cardiovascular causes
15% Malignancies
8% GI causes
8% Other GI causes
5% Emphysema COPD
Patients > 80 years 30 day mortality/%
NZ resident 30 day mortality
age
male
60 – 64
0.07
65 – 69
0.12
70 – 74
0.19
75 - 79
0.33
80 - 84
0.5
85 - 89
1.0
90+
1.8
female
0.05
0.08
0.13
0.22
0.4
0.8
1.7
30 day mortality – all GAs, 80+ years/%
Acute
Elective
All
9 (12 for 90+ years)
1.21
ASA 1&2
2.78
0.69
ASA 3
7.77
1.57
ASA 4
19.95
4.79
ASA 5
49.66
-
Male
7.84
Ns
Female
11.34%
NZ Dep 1&2
7.64
NZ Dep 9&10
10.16
Ns
30-day mortality, specific procedures/%
45-64 years
All
80+ years
Cholecystectomy,
elective
0.07
0.16
1.71
Cholecystectomy,
acute
0.64
1.04
5.14
Colo-rectal
resection, elective
0.22
1.7
3.99
Colo-rectal
resection, acute
2.61
8.46
16.0
Cataract, elective
0.08
0.2
(15%
diabetes )
0.25
30-day mortality, specific procedures/%
45-64 years
All
80+ years
Knee replacement,
elective
0.03
0.21
0.94
Hip replacement,
elective
0.07
0.20
0.7
0.85 inc revisions
Hip replacement,
acute
2.3
7.38
9.52
CABG, elective
1.2
1.4
3.0
CABG, acute
2.3
4.3
7.0
Coronary
angioplasty, acute
1.6
2.2
4.9
30-day mortality, complications/%
45-64 years
All
80+ years
Major sepsis, elective 6
11
27
Major sepsis, acute
15
23
44
If diagnosed with PE
8.22
14.33
18.55
PE, all patients
0.02
0.03
0.12
2016 report: day of week mortality
Highlights:
• Weekend ops mortality > weekday (OR 1.43, 1.33)
• More pronounced elective (OR 2.60)
• Less pronounced acute (OR 1.38, 1.25, Monday OR
1.15)
• More pronounced low risk procedures (in ? high risk
patients)
Potential explanation?
• Failure to recognise and treat post-op deterioration
Improving surgical outcomes:
Learning from data about those who died
Give you information on:
– Who: procedure rates, including risk rating
• Informed consent, patient choice
• Choosing the right operation for THAT patient
– Why:
• Intra-op
– Technical skills etc
– Communication
• Post-op management
– Failure to detect deterioration
– Failure to treat in a timely fashion