EXECUTIVE SUMMARY

The Centers for Medicare & Medicaid Services (CMS) has made changes to its inpatient-only list that will shift many older patients to the same-day surgery setting. This makes it important for surgery centers to develop age-friendly sites.

  • Older patients account for more than one-third of surgical procedures.
  • Surgery centers should be aware of health issues exacerbated by age, including delirium (which can be triggered by medication).
  • Older patients might not need the same medication dosage as younger patients.

Patient outmigration from hospitals to ambulatory surgery centers (ASCs) is a trend picking up speed as Medicare removes additional procedures from the inpatient-only list.

ASC volumes rose by 23% in 2017 after doubling their market share between 2015 and 2016.1 The ASC market is predicted to reach as high as $55 billion by 2025.2

One driver of the industry’s growth involves the shifting of Medicare patients from hospital-based surgeries to the ambulatory surgery setting. For example, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule in August 2019 to remove total hip arthroplasty from the inpatient-only list.3 Earlier, in the CY 2018 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems (OPPS/ASC) final rule, CMS had removed total knee arthroplasty from the inpatient-only list.4

These changes, as well as others that moved more surgical cases to the same-day surgery arena, are resulting in ASCs seeing more Medicare and older patients. As the U.S. population ages, not only will surgery be performed more on older patients, it is expected this group will undergo elective procedures at a rate higher than previous generations. This demographic trend will challenge healthcare organizations, including surgery centers, requiring physicians, nurses, and others to learn more about treating geriatric patients.

“There is a lot that we can know ahead of time and provide training for at the surgical center,” says Alice Bonner, PhD, RN, senior advisor on aging and innovation for the Institute for Healthcare Improvement (IHI).

For example, older patients could experience delirium and acute confusion as part of an underlying medical cause or because of medication issues. “Acute confusion in an older person that has some kind of underlying medical cause needs to be investigated to reduce it or to make it go away,” Bonner says. “An older person comes into a surgery center and is given more medication, but an older person does better with fewer medications.”

One of the biggest side effects of narcotics, especially in older patients, is that they are mind-altering drugs, observes Suzanne Salamon, MD, associate chief of geriatric medicine at Beth Israel Deaconess Medical Center in Boston. Physicians and nurses worry about postoperative pain, but there are milder alternatives to preventing pain, she suggests.

There are several reasons to be concerned about opioid use among older adults. One is that patients’ ratio of fat and muscle changes as they age. Older people have more fat, so opioids stay in the body longer for elderly patients than they do for younger ones, Salamon explains. “If you use narcotics for older patients, use the lowest dose possible, and then try to use it as little as possible,” she says. “Start low, go slow.”

If a patient develops post-op delirium, the same principle applies to prescribing antipsychotic medication. “It’s important to know that an 80-year-old might not need the same dose as a 55-year-old, so use tiny doses,” Salamon says.

Another way to reduce confusion in patients is to ensure there is someone who can spend the night with them on the first night after surgery, regardless of whether the patient still is in a hospital or a surgery center. “That’s when people get the most delirious with anesthesia in their body,” Salamon explains. “They wake up in the middle of the night, disoriented, confused, yelling out, and shouting.”

A friend or family member can calm these patients. Caregivers can hold patients’ hand or talk soothingly. Surgery center staff also can be trained to inquire about patients’ healthcare proxy, says Kelly McCutcheon Adams, MSW, LICSW, a senior director at IHI. This conversation-ready work includes ensuring healthcare providers are aware of patients’ end-of-life wishes, if the patient cares to express these.

“What we’ve learned in conversation-ready work that could be of use in helping people prepare for same-day surgery is that surgery centers should know who a person’s healthcare proxy or agent is,” McCutcheon Adams says.

Surgery centers can educate nurses and staff about creating an age-friendly space by following toolkits created for this purpose, such as IHI’s “4Ms” guide they published in April 2019.5 The four Ms include: what matters, medication, mentation, and mobility.

Surgeons and surgery center leaders also should pay attention to their older patients’ presurgery medications and suggest changes, as needed. For example, tranquilizers, sleeping pills, and diabetes medication might affect patients’ anesthesia, Salamon notes. “The more medicines an older patient is on, the more likelihood that there will anesthesia problems,” she cautions. “Physicians need to get them off the medicines they don’t need.”

With older patients, another issue is frailty. “Frail people do less well in surgery,” Salamon says. “It helps with surgery to get people conditioned before they go into surgery, if at all possible. Have them walk a little more; do prehabilitation.”

Surgery centers also should make certain patients are not anemic or are not B12-deficient. Older people often do not absorb B12 as well; thus, they should be tested for this deficiency. Before the procedure, surgeons should advise these patients to take a B12 supplement if their levels are low, according to Salamon. “B12 deficiency is associated with anemia, confusion, and gait problems,” she says. “If you want to get someone up and walking after orthopedic surgery, if they have a low B12 level, it won’t help.”

REFERENCES

  1. Franklin Trust Ratings. ASC surgical volumes grow in 46 of 50 largest markets while hospitals lose share, Feb. 2, 2018. Available at: http://bit.ly/38rpWMG. Accessed Jan. 23, 2020.
  2. Health Industry Distributors Association. 2019 Ambulatory Surgery Center Market Report. Published October 2019. Available at: http://bit.ly/2GkwsJc. Accessed Jan. 23, 2020.
  3. Centers for Medicare & Medicaid Services. Medicare program: Proposed changes to hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs. Fed Reg, Aug. 9, 2019. Available at: http://bit.ly/2RIkIFr. Accessed Jan. 23, 2020.
  4. Centers for Medicare & Medicaid Services. CMS issues hospital outpatient prospective payment system and ambulatory surgical center payment system and quality reporting programs changes for 2018 (CMS-1678-FC), Nov. 1, 2017. Available at: https://go.cms.gov/30OCUkR. Accessed Jan. 23, 2020.
  5. Institute for Healthcare Improvement. Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. April 2019. Available at: http://bit.ly/30Oaszx. Accessed Jan. 23, 2020.