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A stronger emphasis on the needs of elderly patients undergoing surgery

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Regardless of the type of surgery – hip replacement, bone-fracture treatment or tissue removal – patients older than 65 are especially prone to suffering from post-operative complications on account of their frailty. A recent paper written by Professor Dr. Daniel Fürstenau (ECDF / Freie Universität Berlin) and Professor Dr. Dr. Felix Balzer (ECDF / Charité – Universitätsmedizin Berlin), together with research partners from Charité – Universitätsmedizin Berlin and Freie Universität Berlin, throws light on the question of how the exchange of information relevant to the aging process could be of help in integrated digital care.

Why is your study focused on patients older than 65?
In medicine, because of demographic changes, we are dealing increasingly with elderly patients, who usually have more pre-existing medical conditions than younger patients. Such multimorbidity is particularly challenging in surgical medicine. On top of which, elderly people are more likely to be frail, although this doesn’t necessarily have to be the case. There are also young people who meet the criteria for a frailty diagnosis, and, on the other hand, elderly people who are very fit. The good news is that, in principle, frailty is reversible. You can achieve a lot with exercise, nutrition, social inclusion and the like. All this increases patients’ chances of avoiding complications following surgery.

Charité had recently implemented a special track for patients older than 65 years scheduled for elective surgery. What significance does this have for your research work?
The results of our research on frailty will find their way into clinical routine too. Charité is also involved in further projects dealing with the issue of frailty that aim to establish an understanding of the significance of such treatment throughout Germany.

In your study you write that the German health care system allows only limited time for conversations between medical staff and patients. What role does the time factor play with regard to the post-operative frailty of patients?
Following surgery, it is essential to support patients in returning as quickly as possible to their familiar surroundings. Therefore, it is important that sufficient time and support is available to facilitate this step. And later, when they’re in outpatient care, patients need doctors and nurses who find the time to listen to them. This plays a crucial role in the success of the treatment. Equally important is adequate documentation to ensure that all essential information is recorded and that duplicate examinations are avoided. This requires a fair remuneration system for documentation tasks that creates the right incentives; digital support systems could play an important role in this respect.

How can the various stakeholders – doctors in private practices, nursing staff in nursing homes, physiotherapists, medical staff in hospitals, etc. – be better involved, both before and after surgery?
First of all, it is necessary to understand the entire care process from the patient’s point of view, as well as the relevant result parameters. This concerns issues such as the quality of life of those affected and other health outcomes, but also cost aspects that play a role from the point of view of society as a whole. Then the challenge is to design existing incentive systems in such a way that existing interests are reconciled, that is, that a balancing of interests takes place. This can take the form of financial, but also non-financial, incentives for cooperation. In this way, existing fears and hurdles can be reduced while bringing all those concerned into the process. Ultimately, no one can be forced – the environment and conditions must be right. And, of course, digital solutions are also needed to support the smooth running of the process and to simplify cooperation.

What needs to change in order to reduce the number of elderly patients developing frailty-related complications after surgery?
The bottom line is prevention. The sooner it starts, the better. At present, most approaches continue to concern themselves with providing risk stratification in hospitals and building up the fitness preoperatively of those patients whose fitness can be improved. This is achieved, for instance, through targeted training in good nutrition, or physiotherapy. Actually, all this could start much earlier so as to help elderly people even before they need surgery. Just as it’s already being done to some extent in Sweden and Denmark.

How couldthe different parties exchange data relevant to aging in practice?
The technical solutions are already in place. Denmark, for example, has a portal accessible to doctors, patients and other authorized professionals. Automated interfaces and real-time access are desirable. For specific technologies, such as FHIR web services for the health care sector, there are also technical standards. Data exchange could therefore take place in a largely automated manner.

How do you ensure data protection?
Especially when data is being exchanged across institutions, we need detailed data protection and data security concepts to comply with legal requirements. The primary question is which data is to be exchanged for which purpose and in which form. And we need to consider at what point, to what extent and in what form the patient’s consent is needed. We must observe certain legal principles, such as the General Data Protection Regulation and the relevant data protection laws of the German federal states. Once we have dealt with all this, appropriate IT security measures must be developed. Be it end-to-end encryption, as we know it today from many messaging services, or two-factor authentication, in which a numerical code generated by a smartphone must be entered in addition to the password. We shouldn’t regard data protection as something that puts a brake on digitalizing the health care sector, but rather as an opportunity.

What are the next steps in your research project?
We want to take appropriate steps towards expanding in various dimensions the concept for the care of frail patients. The aim here is to implement the concept, scale it spatially and take a closer look at certain aspects, such as cognitive limitations. We also think it makes sense to expand the concept to include patients’ self-assessments and to use other digital technologies such as wearables and intelligent clothing. Here, too, we need interdisciplinary approaches, for instance, in cooperation with designers. We still have lots of work ahead of us in this regard.

Professor Fürstenau, you are a business information scientist, whereas you, Professor Balzer, are a medical doctor and an information scientist. How did you come to cooperate?
We began working together in the context of the Focus Area DynAge, which is a project jointly funded by Freie Universität Berlin and Charité – Universitätsmedizin Berlin. We proposed a research project on the subject of frailty in elderly patients. That’s how our collaboration started.

In what ways do you benefit from each other?
We cooperate very well on several levels. We jointly supervise students at bachelor’s, master’s and PhD level, and we work together on papers and project proposals. Our different subject backgrounds are enriching in this regard. They contribute different perspectives and methods. Many issues are so complex that they can only be addressed in teams composed of members with different backgrounds. And this is especially true in medicine. (sim)