Cognitive outcome of surgery: is there no place like home?

O nce upon a time, being " in a home " was a pejorative. Now, thanks largely to the government's uncontrolled experiment in health care reform, everyone seems to want in. At least physicians do. " Homes " are popping up everywhere. One type currently under construction and described by several articles in this month's issue of Anesthesia & Analgesia is the " perioperative surgical home. " The perioperative surgical home concept is simple enough: better care, better service, and lower costs through standardization of the continuum of surgical care. 1 It's a nice idea but there are at least 2 problems. One is that the ability of such health care redesign to achieve these goals is unproven. The second is that most of the cost variability in surgery comes from what happens after hospital discharge and some of the clinical conditions driving these costs are poorly understood and not readily modifiable. Cognitive outcome is a case in point. Delirium and post-operative cognitive dysfunction (POCD) are extremely common in geriatric surgical patients, 2,3 a group the government pays for because they are enrolled in Medicare. After elective major joint replacement or other types of major surgery , about 5% to 15% of elders develop delirium and 25% to 40% and 12% to 15% develop, respectively, early or late POCD. This may not seem like much but it far exceeds the rate of other complications we spend a lot of time talking about and managing. Delirium and POCD are associated with prolonged length of stay, discharge to a place other than home (i.e., the physical place they actually live, not a virtual administrative home), and higher 1-year mortality (e.g., persistent delirium is associated with a 2.9-fold increase [95% confidence interval, 1.9–4.4] in mortality at 1 year). 5–8 In addition, delirium is associated with an accelerated trajectory of cognitive decline to dementia and patients with POCD are more likely to leave the workforce. As such, delirium and POCD are important, expensive mor-bidities, just the kind of problems that theoretically could be improved by standardizing management in a periopera-tive surgical home. An article from Denmark by Krenk et al. 12 in this issue of the Journal puts that theory to the test. Elderly patients having elective total hip or knee replacement surgery (N = 225; median age 68 years) were enrolled prospectively in a fast-track approach to elective total hip or knee surgery …