Value-based payment initiatives now require clinicians to both improve the quality of care and decrease its cost. Comprehensive preoperative assessment of functional status identifies patients likely to have high healthcare utilization, such as prolonged length of stay (LOS), but it is burdensome for both patients and providers.
The Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA), developed specifically for preoperative use, can be completed in less than 10 minutes. This combination of patient survey and provider-administered test evaluates mobility, cognition, and ability to perform activities of daily living (ADLs).
Ashley L. Miller, MD, a resident in the Division of Otolaryngology–Head and Neck Surgery at Brigham and Women’s Hospital, and colleagues demonstrated that VESPA can identify patients scheduled for major otolaryngologic head and neck surgery who are at risk of delayed or complex discharge. Their report appears in Otolaryngology–Head and Neck Surgery.
Between August 5, 2019, and March 11, 2020, the researchers performed 61 VESPA evaluations in the Department of Otolaryngology at Mass Eye and Ear and Brigham and Women’s Hospital. 58 of the patients subsequently underwent ablative procedures with anticipated pedicled or free flap reconstruction and/or total laryngectomy with or without flap reconstruction.
The team retrospectively reviewed patients’ records to determine associations between VESPA scores and postoperative outcomes. On the revised VESPA scale, the maximum score is 18 points (higher scores indicate more impairment). For this cohort, a score ≥14 was established as the cutoff denoting ≥50% increased risk of postoperative complications.
- Mean LOS—11 days
- Delayed discharge (≥1 additional hospital days following documentation of discharge clearance)—22% of patients
- Complex discharge planning (prolonged inpatient stay by ≥1 hospital day for nonmedical reasons and/or change in discharge location)—28%
- Emergency department presentation within 30 days—21%
- Readmission within 30 days—17%
VESPA classified 10 patients (17%) as having low functional status (scored ≥14 points).
In analyses adjusted for the reconstructive procedure category, low functional status independently predicted:
- Delayed discharge—OR, 5.0 (95% CI, 1.2–21.3; P=0.030)
- Complex discharge planning—OR, 5.7 (95% CI, 1.34–24.2; P=0.018)
VESPA score did not predict LOS, emergency department presentation, or readmission.
Opportunities to Individualize Care
Understanding functional status is vital before major otolaryngologic surgery, which often fundamentally affects the ability to communicate and receive nutrition. The patient’s preoperative deficits may be exacerbated.
Furthermore, if a patient has existing difficulties with activities of daily living, such as medication management, it’s reasonable to suspect they may have difficulty with postoperative needs (e.g., surgical wound care and post-laryngectomy speech training).
Especially when a procedure typically has a protracted recovery period, VESPA results will be useful to identify patients who:
- Are candidates for “prehabilitation” (optimization before surgery)
- Need enhanced preoperative counseling about recovery
- Warrant preoperative discharge planning (e.g., investigation and discussion of acute rehabilitation facilities)