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Yale Team Investigates Why Disadvantaged Older Adults Often Have Worse Outcomes After Major Surgery

August 23, 2022
by Jane E. Dee

Robert Becher, MD MS, assistant professor of surgery (general surgery, trauma, surgical critical care), has seen firsthand how disadvantaged older adults often do worse after surgery than adults with more social or financial advantages.

Thomas Gill, MD, Humana Foundation Professor of Medicine (geriatrics) and professor of epidemiology (chronic diseases) and of investigative medicine, has worked with Becher for six years, first as a mentor and then as a collaborator investigating geriatric surgery. This year, that work has resulted in a new R01 grant, with Gill and Becher as multiple principal investigators.

The R01 award, “A Multifactorial Approach to Evaluating Disparities in Outcomes after Major Surgery in Disadvantaged Older Persons,” is funded by the National Institute on Minority Health and Health Disparities. The grant will strengthen collaborations between the Department of Internal Medicine and the Department of Surgery at Yale School of Medicine. “Such truly collaborative grants, sharing equal leadership responsibilities, are rare,” Gill said.

Multiple principal investigator grants from the National Institutes of Health (NIH) are uncommon. “For every six single-PI grants awarded by the NIH, only one multiple-PI grant is awarded,” said Becher. “The NIH created the multiple principal investigator pathway about 15 years ago recognizing that collaboration among equals, requiring a truly team science approach, is sometimes the most appropriate way to address a scientific problem -- meaning that some projects are of a scale and complexity beyond just a single-PI and need the multiple principal investigator team leadership approach.”

Gill and Becher’s new R01 award fits those criteria, bridging the disciplines of geriatrics and surgery. Their entire research program, including the new R01, is informed by Gill’s expertise, experience, and way of thinking as a geriatrician, and Becher’s as a surgeon.

Disadvantaged Older Americans

An important piece of their work will be to develop strategies and interventions to improve outcomes after surgery among older Americans, a demographic that is becoming increasingly diverse, both racially and ethnically. Emma Zang, PhD, assistant professor of sociology and biostatistics, is a co-investigator. As a social scientist and gerontologist, Zang is helping to conceptualize how social determinants may affect surgery outcomes in older adults and helping to operationalize the project’s criteria for defining disadvantaged populations.

“We have done descriptive work identifying some of the individual-level factors of disadvantage, including race, ethnicity, low education, and low income,” said Gill, a leading authority on the epidemiology and prevention of disability among older individuals. “We're also interested in evaluating what are called contextual factors, which have more to do with neighborhoods and what's happening at the county and state level where these persons reside.”

Among the team’s long-term goals is to evaluate, probably in a clinical trial, whether intervening on modifiable factors will improve outcomes after major surgery among disadvantaged older people.

Improving Postsurgical Outcomes

Together with Zang, Gill and Becher’s new R01-funded research builds on their previous work. One is Gill and Zang’s work analyzing data with the Area Deprivation Index, which distinguishes people who are living in neighborhoods that are disadvantaged versus those that are not disadvantaged. “We have published a report demonstrating that persons who are living in disadvantaged neighborhoods have much shorter, active life expectancies than those who live in more advantaged neighborhoods,” Gill explained. Zang, a co-author on this prior paper, is helping to acquire county-level and state-level socioeconomic contextual factors of disadvantage to use in the new study.

The team also will look beyond mortality to issues such as functional recovery after major surgery, evaluating the likelihood that someone will be admitted to a nursing home, both in the long and short term. They also plan to look at how much time a person spends at home in the year after major surgery versus in healthcare facilities.

“We're interested in evaluating what are called patient-centered outcomes, which include functional decline and disability,” Gill said. “We know from our own work, and the work of others, that older persons highly value their independence, and they want to spend as much time as they can at home, in their own environment, as opposed to in healthcare facilities.”

Gill and Becher also are interested in compiling evidence that will allow them to intervene on modifiable risk factors, such as physical frailty, cognitive impairment, or a lack of social support, so that they can improve postsurgical outcomes, especially among disadvantage older persons.

“I think it’s really important to shed a light on, and try and better understand, these issues. Then, most importantly, make a meaningful clinical impact by addressing them,” Becher said.

Additional co-investigators on the R01 award include Ronnie Rosenthal, MD, professor of surgery and surgeon-in-chief, VA Connecticut Healthcare System; and Brent Vander Wyk, PhD, biostatistician, Yale Program on Aging.

Yale Geriatrics is devoted to the health and health care of older adults. We strive to ensure that all older adults, regardless of where they reside, receive care that is informed by cutting-edge discoveries in aging and provided by professionals who are expert in geriatric principles. To learn more about their work, visit Yale Geriatrics.

Submitted by Jane E. Dee on August 23, 2022