Developing Quality Indicators for Elderly
Patients Undergoing Abdominal Operations
Marcia L McGory,
, Paul G Shekelle,
, Laurence Z Rubenstein,
, Arlene Fink,
Clifford Y Ko,
Although the expanding and aging population will likely increase demand for surgical services,
surgeons and other providers must develop strategies to optimize care. We sought to develop
process-based quality indicators for elderly patients undergoing abdominal operations to iden-
tify necessary and meaningful ways to improve care in this cohort.
Through structured interviews with thought leaders and systematic reviews of the literature, we
identified candidate quality indicators addressing perioperative care in elderly patients under-
going abdominal operations. Using a modification of the RAND/UCLA Appropriateness
Methodology, an expert panel of physicians in surgery, geriatrics, anesthesia, internal, and
rehabilitation medicine formally rated and discussed the indicators.
Eighty-nine candidate indicators were identified and categorized into seven domains: comor-
bidity assessment (eg, cardiopulmonary disease), elderly issues (eg, cognition), medication use
(eg, polypharmacy), patient-to-provider discussions (eg, life-sustaining preferences), intraoper-
ative care (eg, preventing hypothermia), postoperative management (eg, preventing delirium),
and discharge planning (eg, home health care). Of the 89 candidate indicators, 76 were rated as
valid by the expert panel. Importantly, the majority of indicators rated as valid address processes
of care not routinely performed in younger surgical populations.
Attention to the quality of surgical care in elderly patients is of great importance because of the
increasing numbers of elderly undergoing operations. This project used a validated methodol-
ogy to identify and rate process measures to achieve high-quality perioperative care for elderly
surgical patients. This is the first time quality indicators have been developed in this regard.
(J Am Coll Surg 2005;201:870–883. © 2005 by the American College of Surgeons)
An important area of concern in our current health care
system is improving quality of care. Improvements in the
quality of health care will likely make the largest impact
in populations at greatest risk. Elderly patients undergo-
ing surgical intervention are one example of a popula-
tion at risk. The US population is aging and, according
to the US Census Bureau, one of the fastest growing
segments of the population are individuals over the age
of 65, with their numbers expected to increase 13% by
2010 and Ͼ 50% by 2020.
These population changes
will not only affect health-care delivery but also use of
health-care resources. According to the National Hospi-
tal Discharge Survey in 1999, patients age 65 years and
older constituted 12% of the population, yet used 48%
of inpatient care days and contributed to 40% of hospi-
tal discharges. In addition, the aging of the US popula-
tion will result in a 31% increase in the general surgery
As an increasing number of elderly patients
undergo surgical procedures, the effects of poor-quality
surgical care will become magnified. Development of
methods to measure and improve quality of care for
elderly patients undergoing operations is becoming in-
Competing Interests Declared: None.
Supported by grants from UniHealth Foundation, Hartford Foundation and
American Geriatrics Society, and Robert Wood Johnson Clinical Scholars
Program at UCLA.
Presented at the Symposium “Surgery in the Elderly Patient—Galveston II,”
Galveston, TX, April 2005. This symposium was generously supported by
Genitzinger Endowment Fund, the Sealy Center for Aging and the Depart-
ment of Surgery, UTMB, and the American Geriatric Society.
Received April 27, 2005; Revised July 14, 2005; Accepted July 18, 2005.
From the Department of Surgery (McGory, Ko) and Department of General
Internal Medicine and Health Services Research (Fink), David Geffen School
of Medicine at University of California, Los Angeles, CA; and the Depart-
ment of Medicine (Shekelle, Rubenstein) and Department of Surgery (Ko),
VA Greater Los Angeles Healthcare System, Los Angeles, CA.
Correspondence address: Marcia L McGory, MD, Department of Surgery,
David Geffen School of Medicine, University of California, Los Angeles,
72-215 Center for Health Sciences, Box 956904, 10833 Le Conte Ave, Los
Angeles, CA 90095-6904.
© 2005 by the American College of Surgeons ISSN 1072-7515/05/$30.00
Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2005.07.009