VESPA: a tool for assessing outcomes in a post operative setting

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Published: 15 Nov 2017
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Dr YaoYao Pollock - UCSF School of Medicine, San Francisco, USA

Dr Pollock talks to ecancer at SIOG 2017 in Warsaw about the benefits of the VESPA (Vulnerable Elders Surgical Pathways and Outcomes Assessment) tool.

This tool combines a wide range of variables such as severity of the surgery, and co-morbidities in order to identify the most predictive factors. 

This provided a scoring system to predict risk of post-operative complications. 

Dr Pollock would recommend the tool being used more widely, particularly for those which don't specifically have a geriatric clinic, so that it can be easily integrated in places with fewer resources.

Furthermore it could easily be integrated into the electronic medical system which would make documentation simpler.  

This service has been kindly supported by an unrestricted grant from Janssen Oncology.

VESPA stands for Vulnerable Elderlies Pathways and Outcomes Assessment. The reason that we developed that was that there are a lot of tools to assess older adults in the pre-operative setting but unfortunately most of the tools looked at post-surgical complications and mortality and very few of them looked at functional outcomes, meaning can the older adult stay independent and take care of themselves after surgery as well as geriatric outcomes, so develop delirium, things like falls and malnutrition. So we wanted a tool that can more comprehensively predict outcomes that are uniquely important to older adults.

And did it work?

Yes. Initially we assessed a number of different risk factors, different geriatric as well as comorbidity of the patient. We also included the complexity of the surgery as well in the score and then we did some univariate and multivariate analysis and identified the items that were individually predictive as well as predictive in the multivariable analysis. So we were able to then assign a scoring system and tested how well it fitted to the risk, to predicting risk, in post-operative complications.

Do you have any stats that describe the outcome?

Yes. When we do these predictive models one way that we can use to assess how well there’s a predict in outcome is using the area under the receiver operating curve. So a score of 0.5 means that it’s just as good as chance alone to predict the risk; a 1.0 is perfect prediction. Our predictor model was 0.76 and for pre-operative risk assessment it’s pretty similar to some of the other studies such as there is a cancer aging research group, it’s called CARG, chemotoxicity risk. The area under the curve of these risk predictors that we use often is about 0.7 or above.

Would you recommend taking the VESPA model forward for clinics?

Yes. The reason we developed this was that we know that unfortunately every institution has a geriatric oncology clinic. Ideally we would like to have it but we don’t. But we do know that a lot of large centres have a pre-operative clinic, so a lot of surgeons send their patients to be evaluated in the pre-operative setting in the central clinic. That’s what we have so we thought that this tool is really well fitted for institutions that may not have all the resources to have a geriatric oncology clinic but may have some that we think that this tool can be really easily integrated. The reason that we think it’s easily integrated is that, one, it doesn’t require any special geriatric training so you don’t need a geriatrician, you don’t need a geriatric nurse to complete it. In our study it was surgical physician assistant that completed the assessment. Then two is that it’s pretty quick. Initially when we did the study we assessed more factors than what ended up in the scoring system and even with the longer one it took about ten minutes or less. So with this score that’s even more abbreviated, using only the variables that were predictive of outcomes, it probably would be even shorter.

Then for our institution what’s exciting is that we’re actually integrated into the electronic medical system so that we can then easily integrate it into the documentation as well as ordering different interventions when the risk score is really high.

What stands out about VESPA?

There are a lot of different geriatric assessment tools and I don’t think one is particularly better than the other. But I do think what our tool adds is the functional outcome that’s assessed. But it really depends on the availability of the clinic so for clinics that don’t have a person to do the assessment, maybe a self-assessment, a patient-reported assessment, would be more appropriate. But we are really excited about our VESPA, particularly in our institution and hopefully in other institutions as well.