Preparing older adults for major abdominal surgery: a systems engineering approach to implement preoperative comprehensive geriatric assessments

项目摘要/摘要

PROJECT SUMMARY / ABSTRACT Older Americans are a growing segment of the population with an increasing need for surgical services, and they suffer a disproportionate burden of postoperative complications compared to their younger counterparts. There are opportunities to reduce risk and improve surgical care delivery for this vulnerable population. Preoperative comprehensive geriatric assessment (pCGA) optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social/environmental support; pCGA has been shown to decrease postoperative morbidity, mortality and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic centers. Systems-engineering and implementation science offer unique tools to reliably improve effective use of this important intervention. The goal of this proposal is to use systems-based engineering methods to tailor and pilot test a user-centered implementation package for the pCGA – one that can be adapted to community-based hospitals in preparation for a multi-site implementation trial. This work will promote equitable access to the pCGA, preserving effectiveness, protecting healthcare resources, and preventing avoidable morbidity and mortality. This goal aligns with the National Institute on Aging’s strategic vision C3 to “Support the development of behavioral interventions based on principles of basic behavioral and social science and designed with an eye to real-world implementation, in line with the NIH Stage Model.” My long-term goal is to improve surgical care for older adults through transdisciplinary research that promotes implementation and dissemination of effective, evidence-based, patient-oriented interventions. This 5-year K23 proposal will provide me with mentored research experience and formal training in implementation science, systems-engineering, clinical trials and aging research. With my strong background in surgical health services research, I am well positioned to conduct this project and transition to research independence, with the support of a team of expert mentors at an institution with an outstanding research environment. The proposed research aims are to: 1) Map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery 2) Co-design an implementation package for the pCGA applicable to a diverse population of older patients undergoing major abdominal surgery at (2a) a large academic hospital and (2b) an affiliate community site, and 3) Test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. Upon completion of this project, I will have an adaptable, user-centered implementation package for pCGA with preliminary pilot data on implementation and effectiveness, which will serve as the basis for an R01 proposal to conduct a multi- site hybrid implementation-effectiveness clinical trial of the pCGA in older adults undergoing abdominal surgery.