At 100 years old, most patients aren’t candidates for complex heart procedures, Surgeons at the Ralph H. Johnson VA Health Care System in Charleston, SC, successfully performed a high‑risk cardiac intervention on a 100-year-old veteran last month. U.S. Navy Veteran Lee McKinnon, whose full name is McKinnon Lee Oatice, is surrounded by his surgical and care team in the photo. Source: VA
SALT LAKE CITY — A program developed to address the challenges that older adults experience when undergoing surgery has improved the coordination of care for older veterans and promoted safer, more goal-aligned surgery for older adults, according to a recent study.
The study published in the Journal of the American Geriatrics Society examined the effectiveness of the Care Coordination and Optimization in Geriatric Surgery (COGS) program, a pilot initiative that integrated comprehensive geriatric assessment and targeted optimization into routine surgical care for veterans.1
Older adults undergoing surgery, particularly veterans, face unique challenges, including increased risk for complications, functional decline and prolonged recovery due to frailty and other age-related vulnerabilities. Studies have found that 1-year postoperative mortality rates in older adults are up to 13.4%, with frailty—associated with adverse surgical outcomes—being a major risk factor.
Preoperative geriatric assessment and optimization have been shown to improve outcomes, reduce complications and shorten length of stay. These approaches may also reduce postoperative delirium, preserve functional status, enhance surgical decision-making, improve goal-concordant care and support adherence to multidisciplinary perioperative guidelines, the authors suggested.
The research team developed and implemented the COGS program by learning from established perioperative geriatrics programs across the country. The program shares conceptual similarities with the Duke Perioperative Optimization of Senior Health (POSH) program and other perioperative geriatric initiatives within the VA and the American College of Surgeons (ACS)/Geriatric Surgery Verification (GSV), but there are important differences in structure, implementation and clinical workflow. COGS is embedded directly within surgical clinics, and the geriatrics team evaluates patients in real time alongside the operating surgeon and surgical staff during routine surgical visits. The program is also designed to be scalable without requiring universal geriatric consultation or a standalone geriatric clinic, the researchers explained.
The COGS program was customized to local needs across seven surgical clinics within a large tertiary hospital setting. The investigators used the Risk Analysis Index-Clinical (RAI-C) to identify higher-risk veteran patient through pre-clinic registered nurse review, same-day screening or direct geriatric assessment. The RAI-C tool categorizes patients as robust (less than or equal to 29), normal (30-36), frail (37-44) or very frail (greater than or equal to 45), and veterans were also evaluated at the request of surgical teams regardless of RAI-C score.
The COGS team, which included geriatric providers, nursing and surgical staff, provided individualized evaluation and interventions focused on nutrition, mobility, medication safety, cognition and social support.
Overall, the study authors found the COGS program was feasible, well-received and enhanced the coordination of care for older veterans. The program also aligned surgical decisions with patients’ goals and overall health status.
The analysis revealed the COGS program, which improved outcomes and implemented age-friendly, value-based surgical care, has two key strengths. First, it embeds geriatricians and a geriatrics nurse within surgical clinics to complete geriatric assessments, enabling real-time collaboration among surgeons and geriatricians, shared decision-making about surgical readiness and individualized, goal-aligned care. Second, the program offers a unique framework for integrating frailty assessment and optimization into surgical workflows, identifying high-risk veterans to ensure frailty, comorbidities and functional status are incorporated into surgical planning, the investigators pointed out.
The authors explained that COGS aligns with POSH, VA and ACS efforts to improve care for older adults undergoing surgery, but the program differs in several ways, including its embedded structure, real-time surgeon-geriatrician collaboration and implementation strategy. The program offers a scalable approach that applies perioperative geriatric principles within routine surgical practice, especially in settings where traditional geriatric-led clinic models may not be feasible.
From May 30, 2023, to Dec. 31, 2024, the COGS program completed more than 300 consults. The study found that 155 veterans (53%) proceeded to surgery and 140 (47%) didn’t proceed to surgery. Veterans categorized as frail or very frail were more likely not to proceed with surgery compared to robust or normal groups. Among very frail veterans, 44% didn’t undergo surgery, compared to 21% of the robust group.
The researchers determined that 31 deaths occurred within 180 days of COGS consultation (11%), and, of these deaths, seven occurred within 180 days following surgery. Most deaths occurred among veterans classified as frail or very frail. No causal inference can be made regarding the effect of the COGS intervention on mortality outcomes, the authors noted.
The COGS model is scalable with thoughtful workforce adaptation and receives enough referrals to support one to three new patient evaluations each day. Barriers to implementing the program included limited dedicated clinic space, scheduling constraints and substantial workforce demands. Many referred patients can be seen in-person, including the same day as their surgical visit. To provide coverage across all surgical clinics at the researchers’ institution, the model would require an estimated three full-time employees (1.5 full-time geriatricians and 1.5 full-time nurses). An expanded program model could incorporate geriatric-trained advanced practice providers to extend consult capacity and improve efficiency. In addition, structured telehealth follow-up provides an opportunity to enhance reach across geographically dispersed clinics and reduce in-person burden, according to the investigators.
The authors noted that further evaluation is needed to determine impact of the program on short- and long-term clinical outcomes.
In the future, the researchers plan to expand the COGS program to additional surgical specialties and develop an inpatient pathway to support high-risk veterans. They also want to coordinate with the Salt Lake City VA’s transition of care team to extend follow-up into the post-discharge period, if further funding allows.
The investigators would also like to expand data collection on both patient-centered and clinical outcomes, as well as evaluate the program’s potential to reduce postoperative delirium and lower readmissions and healthcare costs. These findings are essential to inform program refinement, demonstrate value and support dissemination, the study authors suggested.
- Scannell GA, Baraldi CA, Rupper R, Mueller MT, Brenner RJ, White T, Sauer BC, Hansen JL, Eleazer GP. Care Coordination and Optimization in Geriatric Surgery (COGS): A Pilot Program to Improve Surgical Outcomes in Older Adults. J Am Geriatr Soc. 2026 May 23. doi: 10.1111/jgs.70474. Epub ahead of print. PMID: 42175682.
