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Improving outcomes in older vascular surgical patients

Student thesis: Doctoral ThesisDoctor of Philosophy

Older people commonly develop conditions that require definitive management with emergency or planned surgical procedures. Adverse postoperative outcomes are more common in these older patients in comparison to younger cohorts. This can be attributed in part to the pathophysiological profile of older people, who often present for surgery with coexisting physiological decline, multimorbidity and geriatric syndromes. The risk factors for vascular disease may put the vascular surgical population at particularly high risk of adverse postoperative outcomes. Preoperative Comprehensive Geriatric Assessment (CGA) and optimisation has not yet been studied in vascular surgical patients as a method to improve postoperative outcomes. 
The overall programme of research presented in this thesis aims to design and evaluate an intervention to improve postoperative outcomes in older vascular patients, according to the Medical Research Council framework for ‘Developing and Evaluating Complex Interventions’. 
First, a systematic review and narrative synthesis of existing literature found that preoperative CGA and optimisation may improve postoperative outcomes in older patients undergoing elective surgery. Second, a national UK wide survey identified only three trusts providing CGA and optimisation-based input throughout the perioperative pathway for older surgical patients. Geriatricians who responded to the survey cited funding and workforce issues as the main barriers to developing such services. Third, an observational study described a high prevalence of frailty and cognitive impairment in older vascular surgical patients and showed that the combination of frailty and cognitive impairment contributes to postoperative morbidity and length of hospital stay. The use of brief assessment tools was shown to be acceptable and feasible in the preoperative setting in this study. Fourth, a randomised controlled trial demonstrated that preoperative CGA and optimisation reduced length of stay in older patients undergoing vascular surgery by 40% when compared with standard preoperative assessment. This was predominantly due to fewer medical complications with a trend towards fewer delayed discharges. Finally, an observational study described distress related to postoperative delirium in patients and their relatives. The degree and recall of distress was found to be associated with the severity of delirium and specific phenotypic features of the delirious episode. 
In conclusion, the work presented in this thesis demonstrates that postoperative outcomes for older vascular surgical patients can be improved using a CGA based intervention. This programme of research sets the scene for ongoing work to further investigate patient reported postoperative outcomes and to study the implementation of CGA based perioperative services on a wider scale.
Original languageEnglish
Awarding Institution
Supervisors/Advisors
Award date1 Aug 2019

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