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Supplementary Online Content
Min L, Hall K, Finlayson E, et al. Estimating postsurgical general and geriatric
complications using the VESPA preoperative tool. JAMA Surg. Published online
August 2, 2017. doi:10.1001/jamasurg.2017.2635
eAppendix 1. Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA)
For Elective Surgical Patients Aged 70 Years or Older
eAppendix 2. Evaluation of Implementation and Sustainability
eAppendix 3. Procedures of the Work-related Relative Value Units (WRVU) Groups
eAppendix 4. Outcomes (N=740)
This supplementary material has been provided by the authors to give readers additional
information about their work.
© 2017 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/05/2021eAppendix 1. Vulnerable Elders Surgical Pathways and Outcomes Assessment (VESPA)
For Elective Surgical Patients Aged 70 Years or Older
Functional Status screen:
Have you needed
Have you needed
any help from
any help from another
Basic Activities of Daily Living another person in Instrumental Activities
person in the past two
(BADLs) the past two weeks of Daily Living (IADLs)
weeks to do any of
to do any of the
the following activities
following activities
Feeding
(Eating and drinking, but not the Administering own
No Yes No Yes
preparation of food) medication
Transfers
(Moving into or out of bed, chair or
No Yes Preparing meals No Yes
wheelchair)
Toileting
(Getting to and from toilet, managing
No Yes Using the telephone No Yes
clothing before/after using the toilet,
and cleaning self after elimination)
Driving and
Dressing transportation
No Yes No Yes
(Putting on and taking off clothes) (Calling a taxi or using
the bus)
Grocery shopping
Grooming
(Choosing items in the
(Brushing/combing hair, washing No Yes No Yes
store and checking
face, brushing teeth, etc.)
out)
Housekeeping
Bathing (or other light
(Cleaning/rinsing self in shower, tub No Yes cleaning, e.g., No Yes
bath or sponge bath) dishwashing, picking
up, wiping sinks)
Laundry (or other
heavy housework, No Yes
e.g., vacuuming)
Handling own
finances
(Maintaining bank
No Yes
account, paying bills,
using credit cards,
writing checks)
© 2017 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/05/2021Social History:
A. Household environment
1. When you go home after the surgery, will you have to use stairs
a. To get into your home? Yes No
b. To get to the bathroom for toileting? Yes No
c. To get to the bathroom for bathing? Yes No
d. To get to your bed? Yes No
2. Is your home equipped with:
a. Railings for all stairs including those to enter the home? Yes No
b. Grab bars in the shower/bath? Yes No
c. Other equipment such as shower chair/handheld shower head/ hospital bed?
Yes No please list if yes: _____________________
3. Do you live alone? Yes No
4. Can you manage by yourself for several hours alone right after you are discharged home from the
hospital?
Yes No
5. Is there a family member, friend, or designated person who will be helping you upon discharge?
Yes No
Who? ________________________
6. Have you experienced any falls in the past year? Yes No
B. Two-Item depression screen
1. During the past month, have you often been bothered by feeling down, depressed, or hopeless?
Yes No
2. During the past month, have you often been bothered by little interest or pleasure in doing things?
Yes No
© 2017 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/05/2021Mini-Cog Instructions
Physical Exam: 1. Instruct the patient to listen carefully and repeat the
following: “Ball, Flag, Tree”.
A. MINI-COG 2. Clock: Ask patient to draw the face of a clock. After
numbers are on the face, ask patient to draw hands to read 10
1. 3 object recall: 0 1 2 3 past 11:00.
3. Ask patient to repeat the three words given previously. (1
2. Clock draw test: Correct Incorrect point for each)
Source: Borson et al, Int J Geriatr Psychiatry 2011
If not completed, check reason below:
Patient refused/unable
Clinician did not have time to complete
Timed Get Up and Go Test (TUG) Instructions
The patient may wear their usual footwear and can use any
assistive device they normally use.
B. Mobility 1. Have the patient sit in the chair with their back to the chair
and their arms resting on the arm rests.
1. Timed ‘Get Up and Go’ Test: =20 sec 2. Ask the patient to stand up from chair and walk 10 ft. (3m).
3. Have the patient turn around, walk back to the chair and sit
2. Gait: Normal Unsteady down again.
Timing begins when the patient starts to rise from the chair and
ends when he/she returns to the chair and sits down.
Use of any assistance device? (E.g., walker or cane)
___________________
Predictive Results:
Seconds Rating
If not completed, check reason below: 20 Impaired mobility
Source: Podsiadlo, D., Richardson, S. J Am Geriatr Soc.
1991; 39:142-148
C. WEIGHT LOSS
1a. Height, inches Weight, lbs. BMI
1b. Most recent baseline serum albumin and prealbumin levels
Ask patient:
2a. Has your food intake declined over the past three months due to loss of appetite, digestive
problems, chewing or swallowing difficulties? Yes No
2b. In the past 6 months, has the patient had unintentional weight loss of more than 10%?
Yes No
Nutritional Status
Document patients with severe nutritional risk if they exhibit
any of the following:
a. BMIVulnerable Elders Surgical Pathways and Outcomes Assessment
(VESPA) (Short Form)
Total VESPA Points: _________
1. Gender: Male Female (2 points for male)
2. Functional Status screen (total of 1 point for any “Yes”)
Have you needed any help
from another person in the
Activities of Daily Living (ADLs)
past two weeks to do any of
the following activities
Transfers
No Yes
(Moving into or out of bed, chair or wheelchair)
Dressing
No Yes
(Putting on and taking off clothes)
Bathing
(Cleaning/rinsing self in shower, tub bath or sponge No Yes
bath)
Preparing meals No Yes
Grocery shopping
No Yes
(Choosing items in the store and checking out)
3. Can you manage by yourself for several hours alone right after you are discharged home
from the hospital? (2 points for “No”)
Yes No
4. Total Charlson Comorbidity Index (CCI) Score: ________ (2 points for CCI score >2)
Charlson Charlson
Condition Condition
Score* Score*
Diabetes with Chronic
Myocardial Infarction 1 2
Complications
Congestive Heart
1 Hemiplegia or Paraplegia 2
Failure
Peripheral Vascular
1 Tumor 2
Disease
Cerebrovascular
1 Leukemia 2
Disease
Dementia 1 Lymphoma 2
Chronic Pulmonary
1 Renal Disease 2
Disease
Moderate or Severe Liver
Rheumatologic Disease 1 3
Disease
Peptic Ulcer Disease 1 Metastatic Tumor 6
Mild Liver Disease 1 AIDS 6
Diabetes 1
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.5. Surgery complexity (based on Work-related Relative Value Units of the primary
procedure):
Low Moderate High (2 points for “Moderate” and 9 points for “High”)
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.eAppendix 2. Evaluation of Implementation and Sustainability
This is a more detailed description of methods used to evaluate the success of implementation and
sustainability of the VESPA initiative within the larger UMHS system over a two-and-half year period
from July 9, 2008 to January 5, 2011. We first collected all hospital administrative records for any patients
with a visit to the general surgery pre-operative clinic during the evaluation period. We applied age criteria
(age 70 or older on the day of their pre-operative visit) and excluded any patients who did not have an
operative procedure at UMHS within 3 months. An operative procedure was defined by the primary
Current Procedural Terminology (CPT) codes or International Classification of Diseases, Ninth Revision
(ICD-9) procedure code (if primary CPT code was missing) matching any of 244 Clinical Classifications
Software for Services and Procedures, a method developed by the Agency for Healthcare Research Quality
Health Care Utilization Project (HCUP) to identify patients who receive procedures of at least minor
surgical involvement.25 Thus, the HCUP procedure categories allow for rapid identification of surgical
patients by CPT and ICD-9 procedure codes, grouping them into a more manageable number of procedure
types, such as lumpectomy/quadrantectomy of the breast or colorectal excision. We excluded all non-
operating room categories such as endoscopy or bedside interrogation of devices.
Not all Physician Assistants (PAs) working for the UMHS pre-operative surgery clinic participated in the
VESPA project at all times, because the PA champion (WP) initially trained a core team of PAs at the start
of the project, however, PA turnover occurred over the next 3 years. Although we ideally wished to
evaluate only the efforts of those participating Physician Assistants (PAs), it was not possible using
administrative billing data to identify which patients in the health system were seen by a particular PA.
Therefore, we used specific HCUP procedure categories as a proxy for the surgical areas served by
participating PAs in the VESPA program. Thus, we used the HCUP classification of surgery type to match
the VESPA patients (the numerator) with all older patients age 70+ who also underwent similar surgeries in
the health system within 3 months of their pre-operative clinic visit. Thus, we measured sustainability of
the VESPA tool over time by considering each 6-month increment over a 2.5 year period (for a total of 5
periods), calculated as the number of patients with a VESPA evaluation (“VESPA patients”) divided by all
the eligible patients identified during that period (VESPA + matched control patients not evaluated by
VESPA).
All Patients Age
Matched
70+ Seen in Pre-
Control
Pre-op Evaluation Screening Rate op Clinic with a
VESPA Patients Not
Time Interval (%) Surgery in 90
Evaluated by
Days following
VESPA*
the Pre-op Visit
Overall 736 2357 23.8 3438
July 9, 2008-
247 337 42.3 470
December 31, 2008
January 1, 2009-
229 401 36.4 558
June 30, 2009
July 1, 2009-
85 465 15.5 783
December 31, 2009
January 1, 2010-
102 560 15.4 806
June 30, 2010
July 1, 2010-
73 594 10.9 821
January 5, 2011
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.These longitudinal results show that during the initial 12 months of implementation, greater than one-third
of eligible patients were provided with the VESPA evaluation. Over the next 1.5 years, however, the
evaluation rates decreased to 15% and 11% by the end of the study.
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.eAppendix 3. Procedures of the Work-related Relative Value Units (WRVU)
Groups
Low WRVU Group:
Text description of reported Common Prevalence within the
WRVU
Procedural Terminology codes Group
Acell graft trunk/arms/legs 0 0.82
Acellular graft, f/n/hf/g 0 0.82
Removal of forehead wrinkles 0 0.41
Removal of face wrinkles 0 0.41
Larynx surgery procedure 0 0.41
Laparoscope proc spleen 0 0.41
Excision of rectal lesion 0 0.41
Laparoscope procedure liver 0 0.41
Laparo proc hernia repair 0 0.41
Place needle wire breast 0.63 0.41
Remove sutures same surgeon 0.78 0.41
Exc tr-ext b9+marg 0.5 cm< 0.9 0.41
Change of bladder tube 0.9 0.41
Exc face-mm b9+marg 0.5 cm/< 1.05 0.41
Diagnostic laryngoscopy 1.1 0.82
Biopsy eyelid & lid margin 1.18 0.41
Place needle wire breast 1.27 0.82
Incision of eyelid fold 1.27 0.41
Excision of mouth lesion 1.36 0.82
Exc tr-ext b9+marg 1.1-2 cm 1.45 0.41
Skin sub graft trnk/arm/leg 1.5 0.82
Stereotact guide for brst bx 1.59 0.41
Exc tr-ext mal+marg 0.5 cm/< 1.63 11.07
Exc f/e/e/n/l mal+mrg 0.5cm< 1.67 1.64
Percut bx lung/mediastinum 1.93 0.41
Retr bone flap to fix skull 2 0.41
Exc f/e/e/n/l mal+mrg 0.6-1 2.17 0.41
Cystoscopy 2.23 0.41
Exc tr-ext mal+marg 1.1-2 cm 2.27 0.41
Biopsy shoulder tissues 2.3 0.41
Esoph endoscopy dilation 2.34 0.41
Cystoscopy & ureter catheter 2.37 0.41
Cystoscopy w/biopsy(s) 2.59 6.15
Exc f/e/e/n/l mal+mrg 1.1-2 2.62 0.41
Deb musc/fascia 20 sq cm/< 2.7 0.41
Exc tr-ext mal+marg 2.1-3 cm 2.82 0.41
Placement of seton 3 0.41
Probe nl duct w/balloon 3.06 0.41
Exc s/n/h/f/g mal+mrg 2.1-3 3.11 0.41
Laryngoscopy w/biopsy 3.16 0.41
Exc tr-ext mal+marg 3.1-4 cm 3.17 2.05
Upper GI endoscopy/tumor 3.2 0.41
Biopsy of breast open 3.23 0.41
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.Nasal/sinus endoscopy surg 3.26 0.41
Circum 28 days or older 3.32 0.41
Bronchoscopy w/biopsy(s) 3.36 0.41
Repair eyelid defect 3.47 0.41
Exc tr-ext b9+marg >4.0 cm 3.52 0.82
Laryngoscopy w/bx & op scope 3.55 3.28
Exc s/n/h/f/g mal+mrg 3.1-4 3.62 0.41
Repair eyelid defect 3.75 0.41
Exc leg/ankle tum < 3 cm 3.96 1.23
Exc neck les sc < 3 cm 3.96 0.82
Cystoscopy and treatment 4.05 0.41
Deb bone 20 sq cm/< 4.1 0.82
Remove tonsils and adenoids 4.22 0.41
Place gastrostomy tube 4.32 0.41
Nipple exploration 4.44 0.41
Incise & drain bladder 4.49 0.82
Larynscop w/tumr exc + scope 4.52 2.05
Nasal/sinus endoscopy surg 4.57 0.41
Exc s/n/h/f/g mal+mrg >4 cm 4.61 0.41
Cystoscopy and treatment 4.62 0.82
Cystoscopy and treatment 4.99 0.41
Exc tr-ext mal+marg >4 cm 5.02 1.64
Removal of anorectal lesion 5.12 0.41
Removal of ethmoid sinus 5.14 0.41
Diag laparo separate proc 5.14 0.41
Removal of breast tissue 5.31 0.41
Remove anal fist inter 5.42 0.82
Cystoscopy and treatment 5.44 2.05
Laparoscopy biopsy 5.44 0.41
Endoscopy maxillary sinus 5.45 0.82
Implant spine infusion pump 5.6 0.41
Removal of breast lesion 5.92 1.64
Repair eyelid defect 6.05 0.41
Excise submaxillary gland 6.14 0.41
Repair eyelid defect 6.19 0.82
Mohs 1 stage h/n/hf/g 6.2 0.82
Remove vc lesion w/scope 6.3 0.41
Tis trnfr trunk 10 sq cm/< 6.37 0.41
Biopsy/removal lymph nodes 6.43 1.23
Rpr umbil hern reduc > 5 yr 6.59 0.82
Amputation toe & metatarsal 6.64 0.82
Excision breast lesion 6.69 5.33
Remove in/ex hem groups 2+ 6.73 0.41
Biopsy/removal lymph nodes 6.74 0.82
Removal of wrist prosthesis 6.77 0.41
Repair brow defect 6.82 0.41
Removal of ethmoid sinus 6.95 0.41
Repair of nasal septum 7.01 0.82
Removal neck/armpit lesion 7.11 0.41
Implant neuroelectrodes 7.15 0.41
Incision of windpipe 7.17 0.41
Cystoscopy and treatment 7.5 2.05
Revise eyelid defect 7.5 0.41
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.Repair eyelid defect 7.59 0.41
Exc neck tum deep < 5 cm 7.66 0.41
Incision of prostate 7.78 0.41
Prp i/hern init reduc >5 yr 7.96 11.07
Mediastinoscopy incl biopsy 8.05 0.41
Exc rect tum transanal part 8.13 0.41
Exc abdl tum deep < 5 cm 8.32 0.41
Contour of face bone lesion 8.39 0.41
Repair rectum-vagina fistula 8.71 0.41
Remove eye/insert implant 8.84 0.41
Repair ing hernia sliding 8.93 0.41
Tis trnfr e/n/e/l 10 sq cm/< 9.23 0.41
Excise parotid gland/lesion 9.57 0.82
Tis trnfr s/a/l 10.1-30 sqcm 9.72 0.41
Total 100.00
Moderate WRVU Group:
Text description of reported Common Prevalence within the
WRVU
Procedural Terminology codes Group
Resect face tum < 2 cm 9.89 1.22
Create tear duct drain 9.9 0.41
Create tear sac drain 9.96 0.41
Rerepair ing hernia reduce 9.99 1.22
Excision of bone lower jaw 10.03 0.41
Repair eardrum structures 10.05 0.81
Create tear duct drain 10.1 0.81
Partical mastectomy 10.13 17.07
Skn splt a-grft fac/nck/hf/g 10.15 0.41
Repair bladder neck 10.15 0.41
Skin full grft face/genit/hf 10.41 0.41
Cataract surg w/iol 1 stage 10.43 4.88
Laparoscopic cholecystectomy 10.47 8.94
Appendectomy 10.6 0.41
Pedcle fh/ch/ch/m/n/ax/g/h/f 10.7 0.41
Tis trnfr f/c/c/m/n/a/g/h/f 10.83 0.81
Partial thyroid excision 11.23 1.63
Laser surgery of prostate 11.3 0.41
Rerepair ing hernia blocked 11.48 0.41
Revision of scrotum 11.78 0.41
Island pedicle flap graft 11.8 0.41
Remove palate/lesion 11.86 0.41
Av fuse uppr arm cephalic 11.89 0.41
Rpr ventral hern init reduc 11.92 1.22
Lap vent/abd hernia repair 11.92 0.41
Revise middle ear bone 12.03 0.81
Exc rect tum transanal full 12.13 0.41
Repair bladder defect 12.13 0.41
Laser surgery of prostate 12.15 0.41
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.Rerepair ventrl hern reduce 12.37 4.47
Repair of abdominal wall 12.41 0.81
Reconstruct cleft palate 12.53 0.41
Rpr hern preemie reduc 12.53 0.41
Exploration of abdomen 12.54 0.41
Mastoidectomy 12.56 0.41
Open biopsy of lung pleura 12.91 0.41
Resect forearm/wrist tumMast simple complete 15.85 4.00
Reduction of large breast 16.03 0.40
Excision of stomach lesion 16.34 0.40
Remove spine lamina 1/2 lmbr 16.43 0.40
Resect abd tum < 5 cm 16.69 0.80
Laser treatment of retina 16.74 0.40
Lap inc hern repair comp 16.84 0.40
Reconstruction of urethra 17.02 0.40
Mast radical 17.46 0.40
Removal of thyroid 17.62 0.40
Reopening of abdomen 17.63 0.40
Resect shoulder tum < 5 cm 17.66 0.80
Implant cochlear device 17.73 4.40
Removal of chest wall lesion 17.78 0.40
Explore adrenal gland 18.02 0.80
Mast mod rad 18.23 0.80
Extensive jaw surgery 18.37 0.40
Freeing of bowel adhesion 18.46 1.20
Remove kidney open 18.68 2.40
Muscle-skin graft leg 19.04 0.40
Removal of spleen total 19.55 0.80
Fusion of ureters 20.07 0.40
Reconstruction of urethra 20.7 0.40
Laparo ablate liver cryosurg 20.8 0.40
Removal of small intestine 20.82 0.40
Laparo ablate renal mass 21.36 0.40
Transab esoph hiat hern rpr 21.46 0.40
Removal of thyroid 22.01 0.40
Lumbar spine fusion 22.09 0.40
Transthor diaphrag hern rpr 22.12 0.40
Partial removal of colon 22.59 4.00
Lap colectomy part w/ileum 22.95 0.80
Removal of thyroid 23.2 4.00
Vit for membrane dissect 23.24 0.80
Fuse esophagus & stomach 23.31 0.40
Removal of lymph nodes neck 23.95 1.20
Repair bowel-skin fistula 24.2 0.40
Partial removal of kidney 24.21 2.80
Extensive prostate surgery 24.29 3.20
Removal of stomach partial 24.51 0.40
Extensive prostate surgery 24.63 0.40
Suture small intestine 24.72 0.40
Repair rectum/remove sigmoid 24.8 7.20
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.Partial removal of pancreas 26.32 0.40
Laparo partial colectomy 26.42 1.20
Laparo partial nephrectomy 27.41 0.40
Partial removal of colon 27.79 0.80
Extensive thyroid surgery 28.42 0.40
Partial removal of colon 28.58 0.40
Revise & repair chest wall 29.3 0.40
Lap gastric bypass/roux-en-y 29.4 0.80
Removal of pancreas 29.45 2.40
Removal of rectum 30.76 0.40
Resect apical lung tumor 31.74 1.20
Removal of bladder & nodes 34.18 10.80
Removal of colon/ileostomy 34.42 0.40
Removal of stomach partial 35.14 1.20
Remove bladder/revise tract 36.33 1.60
Lap remove rectum w/pouch 36.5 1.60
Free myo/skin flap microvasc 36.94 0.80
Partial removal of liver 39.01 3.60
Craniofacial approach skull 39.13 0.40
Removal of esophagus 44.18 0.80
Remove bladder/create pouch 44.26 1.20
Infratemporal approach/skull 47.04 0.40
Pelvic exenteration 49.1 0.40
Fuse liver ducts & bowel 52.19 0.40
Pancreatectomy 52.79 0.40
Partial removal of pancreas 52.84 4.00
Total 100.00
Downloaded From: https://jamanetwork.com/ on 11/05/2021 © 2017 American Medical Association. All rights reserved.eAppendix 4. Outcomes (N=740)
Outcomes No. (%)
Delirium 43 (5.8)
Pressure Ulcer 6 (0.8)
Geriatric
Fall 10 (1.4)
Complication
Malnutrition 104 (14.1)
Any Geriatric Complication 131 (17.7)
NSQIP Traditional Post-surgical Complication§ 99 (13.4)
Surgical Death in 30 days 7 (0.9)
Complication Unplanned Readmission 33 (4.5)
Any Surgical Complication 114 (15.4)
Any Geriatric or Surgical Complication 187 (25.3)
§Prevalence of Each NSQIP Traditional Post-surgical Complication
NSQIP Traditional Post-surgical Complication Description No. (%)
Acute Renal Failure 4 (0.5)
Transfusion Intraop/Postop 3 (0.4)
DVT Requiring therapy 5 (0.7)
Peripheral Nerve Injury 1 (0.1)
Pneumonia 13 (1.8)
Pulmonary Embolism 1 (0.1)
Sepsis 4 (0.5)
Unplanned Intubation 2 (0.3)
Urinary Tract Infection 45 (6.1)
Septic Shock 2 (0.3)
C. Diff Positive or Colitis 8 (1.1)
Atrial Fibrillation 8 (1.1)
Significant Postop Delirium 3 (0.4)
Pancreatitis 1 (0.1)
Arrhythmia 12 (1.6)
Cardiac Arrest 1 (0.1)
Fascia Dehiscence 2 (0.3)
Deep or Organ/Space Incisional SSI 13 (1.8)
Superficial Incisional SSI and Superficial Wound Disruption 32 (4.3)
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