Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review

Our systematic review of literature published since 2016 identified five studies of perioperative multicomponent interventions in frail patients undergoing elective oncologic gastrointestinal surgery. There were two RCTs and three quasi-experimental study designs and overall, the quality of the evidence was deemed to be fair. The studies did not consistently demonstrate improvements in outcomes. Reductions in postoperative complications, mortality, length of stay and functional deterioration were reported yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care.

In 2017, McIsaac et al. [7] also found that studies of multicomponent interventions did not consistently demonstrate improvements in outcomes. They attributed this, in part, to poor adherence and protocol implementation issues [7]. Certainly, there is evidence for a dose-response relationship between ERAS protocol adherence and clinical outcomes after major colorectal surgery [15] and it is probably reasonable to expect a similar effect with other perioperative interventions. Protocol adherence was identified as an issue in two studies [10, 11] included in our review. The interventions in these two studies were embedded within a well-established ERAS program and, interestingly, the authors speculated that the study interventions may have had a limited effect, especially with respect to surgical outcomes, given that other aspects of perioperative care were optimised [10, 11].

The sample sizes of included studies were modest – only one study was adequately powered for the primary outcomes (and found no significant difference between the intervention and control groups for any outcome) [10]. The quasi-experimental studies [12‐14] were retrospective and there were important differences in baseline characteristics in both quasi-experimental [12, 13] and RCT studies [11]. Statistical analyses were largely unadjusted, failing to account for potential confounding factors. For example, a statistically significant difference in mortality rates in intervention and control groups in Mazzola et al.’s [12] study may have been confounded by differences in the rates of pancreatic cancer, a malignancy associated with an extremely poor prognosis [16].

There was substantial variability among the interventions tested and, as such, it is difficult to ascertain which elements are the key ingredients for an effective intervention in this setting and patient population. All studies addressed physical activity and nutrition, which is in keeping with ERAS guidelines for elective colorectal surgical patients [17]. Nutrition and physical activity interventions, addressing protein/caloric supplementation and resistance-based training, respectively, are also recommended for the management of frailty more generally [18]. Health domains known to be relevant to the care of frail adults, such as social support, was not addressed by the interventions in the included studies and only one study [11] included a review of medical co-morbidity and medications in their intervention.

Comprehensive Geriatric Assessment (CGA) is a comprehensive evaluation by a medical specialist with expertise in geriatric medicine to identify and address medical, social and functional needs, optimise medication prescribing, and engage a multidisciplinary team to assist frail patients to attain goals [19]. It is, by definition, a multicomponent intervention. Recommended by Best Practice Guidelines as the approach to managing frailty in all patients [20], CGA has been shown to increase the likelihood of frail inpatients being alive and in their own homes at follow-up [21]. The study by Ommundsen et al. [11], which we included in our systematic review, described an intervention including a geriatric assessment and tailored management plan. This intervention appears to align with the principles of CGA; however, the authors of the study noted that there was minimal access to multidisciplinary allied health input and the time between assessment and surgery was very short (median = 6 days). The intervention did not appear to reduce the rates of traditional adverse surgical outcomes in this relatively small study, which is consistent with meta-analysis of data from studies of preoperative CGA in elective non-cardiac high-risk surgery [22]. Even so, preoperative CGA is recommended in recent clinical practice guidelines for the perioperative care of frail people undergoing surgery [23].

Three studies included in our review were ‘prehabilitation’ studies implementing interventions between five days and four weeks prior to surgery [10, 12, 13]. Prehabilitation is designed to improve an individual’s resilience prior to elective surgery [24]. The evidence suggests that preoperative interventions need to be implemented a reasonably long time, at least four weeks, prior to surgery in order to build physiological reserve [25]. However, this is not always feasible. In cancer surgery, for example, delays in treatment can result in poor oncological outcomes. Neoadjuvant therapy increases the time from diagnosis until surgery [26] and is associated with a decrease in overall physical fitness, which has been associated with worse outcomes after surgery [27, 28]. Variations in the timing of intervention likely contributes to variability of the study results reported here. Notably, due to there being “no evidence that prehabilitation programmes improve postoperative outcomes for older patients or those living with frailty” (p. 3), current guidelines advocate the use of CGA [23].

The intervention evaluated by Suzuki and colleagues [14] primarily occurred in the postoperative period. While it was not a CGA, the intervention addressed multiple health domains with the support of a multidisciplinary team of medical and allied health professionals. Although it was a small study, it demonstrated significantly lower complications and dependence in the intervention group. Compared with the other studies included in this systematic review, the results of Suzuki et al.’s [14] study may be more generalisable to emergent surgical populations who are able to receive postoperative (and not preoperative) interventions. CGA conducted postoperatively in hip fracture patients, for example, has been shown to reduce the risk of mortality, readmission and new institutionalisation [29].

Heterogeneity of outcome measures was identified by McIsaac and colleagues [7] as a key issue in their systematic review. In our review, effectiveness was primarily measured using a variety of traditional surgical outcomes. It is possible, however, that perioperative interventions in frail surgical patients will have minor effects on traditional outcomes and major effects on patient-centred outcomes such as functional decline, quality of life and discharge disposition. In our systematic review, four studies reported on patient-centred outcomes. None of the studies examined effects of intervention on delirium or cognitive decline, which along with functional decline, are increasingly prioritised by older patients and are of critical importance to informed surgical decision-making [30]. Furthermore, despite measuring frailty at baseline, none of the studies examined changes in frailty status following multicomponent interventions as an outcome measure. Patient-centred outcomes are not commonly evaluated in clinical trials of frail patients in hospital [31]. The evidence suggests that many patients with severe illness would not elect for life-sustaining treatment if the burden of treatment was high or if treatment resulted in significant cognitive and functional impairment [32]. We agree with McIsaac and colleagues that ascertaining what outcomes are most important to frail patients and the people who care for them is necessary to inform future clinical trials. This is a focus of ongoing work by our group.