Research

Maria Yefimova, PhD, RN, a Nurse Scientist  from the Office of Research, presented her research entitled “Palliative Care and End of Life Outcomes Following High Risk Surgery” at the Association of VA Surgeons in April 2019. Maria was the only nurse scientist on a multidisciplinary team who conducted this research.

Palliative Care and End of Life Outcomes Following High Risk Surgery

Maria Yefimova, PhD, RN, a Nurse Scientist from Stanford Health Care and Palo Alto VA Hospital, recently led a diverse team consisting of palliative care clinicians, surgeons, health services researchers, and biostatisticians to study palliative care and end-of-life outcomes following high risk surgery.  As the human body ages, the risks associated with surgical procedures tend to increase.  Maria and her team performed a retrospective study on a cohort of veterans who died within 90 days of a high-risk surgical procedure to characterize perioperative palliative care and its influence on family reported end-of-life outcomes. This was an opportunity to utilize big data to answer a clinical question, does perioperative palliative care help families, and generate new knowledge for the medical world.

Background:

As a prospective study, answering this clinical question could take years. Instead Maria and her team opted for a retrospective study and obtained access to a dataset of administrative data from a national cohort of veterans who underwent a high-risk surgical operation between 2012-2015, which equated to n=95,204 veterans.  By utilizing the available data, the team was able to determine significant key components related to the clinical question from the records.  The data was organized to control for certain covariates, such as age, gender, and race/ethnicity, which all have been shown in previous research to vary surgical outcomes.  The data was further refined to include only patients who had died within 90 days of the high-risk surgery, and whose family members completed the bereaved family survey (n=1,124).  Finally, the team identified which patients were provided a palliative care consultation either 30-days perioperatively or 90-days postoperatively.

The overall results yielded that patients and families who received palliative care consultation were more likely to rate end-of-life care as “excellent” than those who did not. Additionally, out of the 95,204 veterans who underwent high-risk operations, only 3.75% received palliative care consultation, and it varied by sub-specialty. Their research has been presented at the Association of VA Surgeons (AVAS) conference in April 2019.  An abstract for the study from their presentation at the AVAS conference can be found below.

 

Abstract:

Background: Palliative care has potential to improve the support for patients and families undergoing high risk surgery, yet few surgical patients utilize it.

Objectives: To characterize perioperative palliative care and its influence on family reported end-of-life outcomes among veterans who died within 90-days of a high-risk surgical operation.

Methods: This is retrospective cross-sectional cohort study of veterans who underwent one of 227 high-risk operations between 2012 and 2015. We examined the effect of palliative care consultation (PCC) 30-days before or 90-days after surgery on family-reported ratings of end-of-life care. VA surveys all families of inpatient decedents using the validated Bereaved Family Survey. We used a single item for overall end-of-life care, and composite scores for communication and support.

Results: 95,204 Veterans underwent high risk operations in 129 inpatient VA medical centers.

90-day mortality was 6.0% but varied by surgical sub-specialty. In the entire cohort, 3.5% had a PCC, and 0.8% received one before surgery. Among the 5,740 Veterans who died within 90 days, 28.4% had any PCC with 5.6% receiving it before surgery. Families of decedents who received PCC were 47% more likely to rate overall end-of-life care as “excellent” (OR=1.47; 95% CI=1.14-1.88, P=0.007) than those who did not. Similarly, families of decedents who received PCC were more likely than their counterparts to rate end-of-life communication (OR=1.43, 95% CI=1.09-1.87, p=0.004) and support (OR = 1.31, 95% CI=1.01-1.71, p=0.05) as “excellent”.

Conclusion: A cohort of patients undergoing high-risk surgical operations had substantial postoperative mortality, yet only one-quarter of those who died within 90 days of the procedure used palliative care. Palliative consultations were associated with better end-of-life ratings by the family of the decedent.

Implications: The findings support the need for clinical practices that integrate palliative services in the perioperative period.

 

Article By: Maria Yefimova & Monique Bouvier

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