Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri.
Program in Occupational Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri.
JAMA Netw Open. 2022 Mar 1;5(3):e221938. doi: 10.1001/jamanetworkopen.2022.1938.
Falls after elective inpatient surgical procedures are common and have physical, emotional, and financial consequences. Close interactions between patients and health care teams before and after surgical procedures may offer opportunities to address modifiable risk factors associated with falls.
To assess whether a multicomponent intervention that incorporates education, home medication review, and home safety assessment is associated with reductions in the incidence of falls after elective inpatient surgical procedures.
DESIGN, SETTING, AND PARTICIPANTS: This prospective propensity score-matched cohort study was a prespecified secondary analysis of data from the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized clinical trial, which was conducted at a single academic medical center between January 16, 2015, and May 7, 2018. Patients in the intervention group of the present study were enrolled in either arm of the ENGAGES clinical trial. Patients in the control group were selected from the Systematic Assessment and Targeted Improvement of Services Following Yearly Surgical Outcomes Surveys prospective observational cohort study, which created a registry of patient-reported postoperative outcomes at the same single center. The propensity score-matched cohort in the present study included 1396 patients (698 pairs) selected from a pool of 2013 eligible patients. All patients underwent elective surgical procedures with general anesthesia and had a hospital stay of 2 or more days. Data were analyzed from January 2, 2020, to January 11, 2022.
The multicomponent safety intervention (offered to all patients in the ENGAGES clinical trial) included patient education on fall prevention techniques, home medication review by a geriatric psychiatrist (with communication of recommended changes to the surgeon), a self-administered home safety assessment, and targeted occupational therapy home visits with home hazard removal (offered to patients with a preoperative history of falls).
The primary outcome was patient-reported falls within 1 year after an elective inpatient surgical procedure. The secondary outcome was quality of life 1 year after an elective surgical procedure, which was measured using the physical and mental composite summary scores on the Veterans RAND 12-item health survey (score range, 0-100 points, with 0 indicating lowest quality of life and 100 indicating highest quality of life).
Among 1396 patients, the median age was 69 years (IQR, 64-75 years), and 739 patients (52.9%) were male. With regard to race, 5 patients (0.4%) were Asian, 97 (6.9%) were Black or African American, 2 (0.1%) were Native Hawaiian or Pacific Islander, 1237 (88.6%) were White, 3 (0.2%) were of other race, and 52 (3.7%) were of unknown race; with regard to ethnicity, 12 patients (0.9%) were Hispanic or Latino, 1335 (95.6%) were non-Hispanic or non-Latino, and 49 (3.5%) were of unknown ethnicity. Adherence to individual intervention components was modest (from 22.9% for completion of the self-administered home safety assessment to 28.2% for implementation of the geriatric psychiatrist's recommended medication changes). Falls within 1 year after surgical procedures were reported by 228 of 698 patients (32.7%) in the intervention group and 225 of 698 patients (32.2%) in the control group. No significant difference was found in falls between the 2 groups (standardized risk difference, 0.4%; 95% CI, -4.5% to 5.3%). After adjusting for preoperative quality of life, patients in the intervention group had higher physical composite summary scores (3.8 points; 95% CI, 2.4-5.1 points) and higher mental composite summary scores (5.7 points; 95% CI, 4.7-6.7 points) at 1 year compared with patients in the control group.
In this cohort study, a multicomponent safety intervention was not associated with reductions in falls within the first year after an elective surgical procedure; however, an increase in quality of life at 1 year was observed. These results suggest a need for other interventions, such as those designed to increase adherence, to lower the incidence of falls after surgical procedures.
择期住院手术术后跌倒很常见，会对患者造成身体、情感和经济方面的影响。患者在手术前后与医疗团队进行密切互动，可能有机会解决与跌倒相关的可改变的风险因素。
评估包含教育、家庭用药审查和家庭安全评估的多组分干预措施是否与择期住院手术术后跌倒发生率的降低相关。
设计、环境和参与者：这是一项前瞻性倾向评分匹配队列研究，是对 2015 年 1 月 16 日至 2018 年 5 月 7 日期间在单家学术医疗中心进行的电生理监测指导麻醉减轻老年综合征（ENGAGES）随机临床试验数据的预设二次分析。本研究中的干预组患者招募自 ENGAGES 临床试验的任意一个试验臂。对照组患者选自年度手术结局调查系统评估和靶向改进前瞻性观察队列研究，该研究创建了一个在同一单中心报告术后患者结局的患者报告数据库。本研究中的倾向评分匹配队列纳入了 1396 名患者（698 对），这些患者来自 2013 名符合条件的患者的队列。所有患者均接受全身麻醉的择期手术，住院时间为 2 天或以上。数据于 2020 年 1 月 2 日至 2022 年 1 月 11 日进行分析。
多组分安全干预（ENGAGES 临床试验中的所有患者均接受）包括预防跌倒技术的患者教育、老年精神病医生进行家庭用药审查（与手术医生沟通推荐的变更）、自我管理的家庭安全评估以及针对有术前跌倒史的患者进行靶向职业治疗家访和家庭危险物清除。
主要结局是术后 1 年内患者报告的跌倒。次要结局是术后 1 年的生活质量，使用退伍军人 RAND 12 项健康调查的身体和心理综合评分来衡量（评分范围 0-100 分，0 表示生活质量最低，100 表示生活质量最高）。
在 1396 名患者中，中位年龄为 69 岁（IQR，64-75 岁），739 名患者（52.9%）为男性。在种族方面，5 名患者（0.4%）为亚洲人，97 名（6.9%）为黑种人或非裔美国人，2 名（0.1%）为夏威夷原住民或太平洋岛民，1237 名（88.6%）为白人，3 名（0.2%）为其他种族，52 名（3.7%）为未知种族；在族裔方面，12 名患者（0.9%）为西班牙裔或拉丁裔，1335 名（95.6%）为非西班牙裔或非拉丁裔，49 名（3.5%）为未知族裔。个别干预措施的依从性中等（从自我管理的家庭安全评估完成率的 22.9%到老年精神病医生建议用药变更实施率的 28.2%）。术后 1 年内报告跌倒的患者在干预组为 698 名患者中的 228 名（32.7%），在对照组为 698 名患者中的 225 名（32.2%）。两组之间的跌倒率无显著差异（标准化风险差异，0.4%；95%CI，-4.5%至 5.3%）。调整术前生活质量后，与对照组相比，干预组患者的身体综合评分（3.8 分；95%CI，2.4-5.1 分）和心理综合评分（5.7 分；95%CI，4.7-6.7 分）更高。
在这项队列研究中，多组分安全干预措施与术后 1 年内跌倒发生率的降低无关；然而，在 1 年时观察到生活质量的提高。这些结果表明需要其他干预措施，例如旨在提高依从性的干预措施，以降低手术后跌倒的发生率。
