Expanded Preoperative Evaluation

Key Question

Among older patients anticipating surgery and anesthesia, does expanded preoperative evaluation (e.g., for frailty, cognitive impairment, functional status, or psychosocial issues) lead to improved postoperative outcomes?

Balance Tables

Benefits, harms, and strength of evidence (GRADE) for expanded versus standard preoperative evaluation.

			Preoperative Evaluation
Outcome	RCT	NRSI	Expanded	Standard	GRADE*	Effect	Estimate (95% CI)
			N (Total)	N (Total)
Delirium incidence	6		189 (662)	253 (703)	⨁⨁◯◯	RR	0.77 (0.60–0.99)
		6	135 (1,126)	176 (984)	⨁◯◯◯	RR	0.64 (0.47–0.86)
Hip fracture	4		168 (450)	212 (479)		RR	0.84 (0.70–0.99)
Other	2		21 (212)	41 (224)		RR	0.54 (0.33–0.89)
Neurocognitive disorder <30 days		1	13 (96)	16 (84)	⨁◯◯◯	RR	0.71 (0.36-1.39)
Neurocognitive disorder 30 days to 1 yr	none	none
Physical function	5		(563)	(576)	⨁◯◯◯	SMD	0.09 (-0.16 to 0.31)
		4	(407)	(370)	⨁◯◯◯	SMD	0.02 (-0.33 to 0.37)
Complications†	4	9			⨁◯◯◯		see below
Patient satisfaction		1	32 (32)	29 (30)	⨁◯◯◯	RD/100	3.3 (-5.3 to 12.0)‡
Length of stay (days)	8		(968)	(1,001)	⨁◯◯◯	MD	0.0 (-1.7 to 1.7)
		14	(1,972)	(1,889)	⨁◯◯◯	MD	-1.1 (-2.0 to -0.1)
Discharge to institution	4		252 (419)	271 (424)	⨁⨁◯◯	RR	0.98 (0.76-1.27)
		6	345 (855)	336 (668)	⨁⨁◯◯	RR	0.82 (0.63–1.07)
Mortality (in-hospital or 30-day)	4		19 (498)	19 (526)	⨁◯◯◯	RR	1.02 (0.30–3.53)
	5		19 (561)	19 (589)		RD/1000	0.2 (-31.6 to 32.0)
		15	110 (5,746)	205 (7,177)	⨁⨁◯◯	RR	0.66 (0.51–0.85)
		16	110 (5,846)	205 (7,202)		RD/1000	-7.5 (-14.1 to -0.8)
Mortality (1-year)	2		42 (215)	57 (226)	⨁◯◯◯	RR	0.78 (0.54–1.10)
						RD/1000	-57.2 (-134.7 to 20.3)
		5	220 (3,310)	479 (5,722)	⨁◯◯◯	RR	0.77 (0.39–1.52)
						RD/1000	-31.5 (-113.1 to 50.1)
RCT: randomized clinical trial; NRSI: nonrandomized studies of interventions (non-randomized trial, before-after and cohort studies); GRADE: Grades of Recommendation, Assessment, Development, and Evaluation; RR: risk ratio; SMD: standardized mean difference; RD: risk difference; MD: mean difference.
* Very low: ⨁◯◯◯; Low: ⨁⨁◯◯; Moderate: ⨁⨁⨁◯; High: ⨁⨁⨁⨁.
† Cardiovascular, pulmonary, and renal.
‡ High versus lower satisfaction.

Included complications and strength of evidence (GRADE) for expanded versus standard preoperative evaluation.

			Preoperative Evaluation
Outcome	RCT	NRSI	Expanded	Standard	GRADE*	Effect	Estimate (95% CI)
			N (Total)	N (Total)
Myocardial infarction	1	4	9 (811)	12 (714)	⨁◯◯◯	RR	0.58 (0.22–1.53)
						RD/1000	-2.7 (-17.7 to 12.3)
Cardiac arrest	1	1	2 (268)	7 (234)	⨁◯◯◯	RR	0.28 (0.06–1.37)
						RD/1000	17.5 (-47.2 to 12.3)
Acute kidney injury	2	4	85 (808)	104 (805)	⨁◯◯◯	RR	0.83 (0.60–1.16)
						RD/1000	3.4 (-26.8 to 33.7)
Pneumonia	2	7	78 (1,261)	94 (1,198)	⨁◯◯◯	RR	0.82 (0.51–1.32)
						RD/1000	-2.8 (-20.4 to 14.8)
Respiratory failure		1	16 (183)	21 (143)	⨁◯◯◯	RD/1000	-5.9% (-13.0 to 1.2)
Pulmonary embolism		4	6 (468)	5 (354)	⨁◯◯◯	RR	0.90 (0.26–3.08)
						RD/1000	1.2 (-14.6 to 16.9)
RCT: randomized clinical trial; GRADE: Grades of Recommendation, Assessment, Development, and Evaluation; RR: risk ratio; RD: risk difference.
* Very low: ⨁◯◯◯; Low: ⨁⨁◯◯; Moderate: ⨁⨁⨁◯; High: ⨁⨁⨁⨁.

Outcomes Reported

Table 2. Publications reporting dichotomous or count outcomes (not necessarily unique studies).

Outcome	RCT, N = 11	NR Trial, N = 1	Quasi-exp, N = 18	Prosp Coh, N = 1	Retro Coh, N = 2
ADL	1 (9.1%)	—	—	—	—
Complications	5 (45%)	—	12 (67%)	1 (100%)	2 (100%)
DNCR/POCD	—	—	1 (5.6%)	—	—
Delirium	6 (55%)	—	7 (39%)	—	2 (100%)
Delirium duration	—	—	—	—	—
Discharge location	4 (36%)	1 (100%)	4 (22%)	—	1 (50%)
Mortality	7 (64%)	1 (100%)	12 (67%)	1 (100%)	2 (100%)
Opioid use	—	—	—	—	—
Pain	1 (9.1%)	—	1 (5.6%)	—	—
QoR	—	—	—	—	—
Readmission	5 (45%)	—	8 (44%)	—	2 (100%)
Satisfaction	—	—	1 (5.6%)	—	—
ADL: activities of daily living; NCR: neurocognitive recovery; POCD: postoperative neurocognitive disorder; QoR: quality of recovery; RCT: randomized clinical trial; NR Trial: non-randomized trial; Quasi-exp: before-after or time series; Prosp Coh: prospective cohort; Retro Coh: retrospective cohort.

Table 3. Publications reporting continuous outcomes (not necessarily unique studies).

Outcome	RCT, N = 11	NR Trial, N = 1	Quasi-exp, N = 18	Prosp Coh, N = 1	Retro Coh, N = 2
Delirium duration	2 (18%)	—	—	—	—
Length of stay	10 (91%)	1 (100%)	11 (61%)	1 (100%)	2 (100%)
Opioid use	—	—	—	—	—
RCT: randomized clinical trial; NR Trial: non-randomized trial; Quasi-exp: before-after or time series; Prosp Coh: prospective cohort; Retro Coh: retrospective cohort.

Table 4. Publications reporting likert or ordinal outcomes (not necessarily unique studies).

Outcome	RCT, N = 11	NR Trial, N = 1	Quasi-exp, N = 18	Prosp Coh, N = 1	Retro Coh, N = 2
ADL	6 (55%)	1 (100%)	3 (17%)	—	—
DNCR/POCD	3 (27%)	—	—	—	—
Delirium	1 (9.1%)	—	—	—	—
Complications	—	—	—	—	—
Pain	—	—	—	—	—
Quality of life	1 (9.1%)	—	2 (11%)	—	—
QoR	—	—	—	—	—
Satisfaction	—	—	—	—	—
ADL: activities of daily living; NCR: neurocognitive recovery; POCD: postoperative neurocognitive disorder; QoR: quality of recovery; RCT: randomized clinical trial; NR Trial: non-randomized trial; Quasi-exp: before-after or time series; Prosp Coh: prospective cohort; Retro Coh: retrospective cohort.

Included Studies

See Appendix for detailed summary study and patient characteristics including primary outcomes.

Table 5. Number of studies by design.

Design	Studies
Randomized Clinical Trial	9
Nonrandomized Trial	1
Before-After/Time Series	18
Prospective Cohort	1
Retrospective Cohort	2
Total	31
Studies with multiple publications counted once (applies to 2 studies with 2 publications).

Design, centers, country, and surgery

Table 6. Study design, enrollment, centers, country, and surgery (see References for citations).

ID	Study	Centers	Enrolled	Countrya	Surgery
Randomized Clinical Trial
741	Marcantonio 2001	1	126	USA	HipFx
16608	Prestmo 2015	1	397	Norway	HipFx
17156	Shyu 2005	1	159	Taiwana	HipFx
17155	Shyu 2008 (Shyu 2005)	1	162	Taiwana	HipFx
16628	Vidan 2005	1	321	Spain	HipFx
1201	Watne 2014	1	329	Norway	HipFx
16739	Zhu 2022	1	155	Chinaa	HipFx
555	Ommundsen 2018	2	122	Norway	GI/Abd
760	Hempenius 2013	3	297	Netherlands	Variousb
1263	Hempenius 2016 (Hempenius 2013)	3	297	Netherlands	Variousb
16605	Partridge 2017	1	201	UK	Variousb
Nonrandomized Trial
17087	Deschodt 2011	1	171	Belgium	HipFx
Before-After/Time Series
16544	Bjorkelund 2010	1	276	Sweden	HipFx
16629	Vochteloo 2011	1	1056	Netherlands	HipFx
19171	Harari 2007	1	108	UK	Other Ortho
16601	Olsson 2014	2	266	Sweden	Other Ortho
13133	Romano 2021	1	181	Italy	Other Ortho
16846	Giannotti 2022	1	207	Italy	GI/Abd
149	Indrakusuma 2015	1	443	Netherlands	GI/Abd
6017	Souwer 2018	1	149	Netherlands	GI/Abd
18807	Staiger 2023	1	83	Switzerland	GI/Abd
18797	Smoor 2023	1	281	Netherlands	Cardiac
16539	Bakker 2014	1	241	Netherlands	Variousb
2736	Ernst 2014	1	310	USA	Variousb
1313	Hall 2017	1	9153	USA	Variousb
11264	Lester 2022	1	492	USA	Variousb
16591	McDonald 2018	1	326	USA	Variousb
1294	Richter 2005	1	62	USA	Variousb
2108	Braude 2017	1	242	UK	Urol
1189	Adogwa 2017	1	125	USA	Neuro
Prospective Cohort
17128	Jones 2021	1	466	USA	Variousb
Retrospective Cohort
16623	Tarazona-Santabalbina 2019	1	310	Spain	GI/Abd
19377	Paille 2021	1	228	France	Cardiac
GI: gastrointestinal; Ortho: orthopedic; Neuro: neurological; Oralmax: oral maxillofacial; Vasc: vascular.
a Non very-high Human Development Index country.
b Described as various or more than 4 different types of surgery.

Country Summary

Table 7. Summary of studies by country where conducted.

	N = 31a
Country
USA	8 (26%)b
Netherlands	6 (19%)b
Norway	3 (9.7%)
UK	3 (9.7%)
Italy	2 (6.5%)
Spain	2 (6.5%)
Sweden	2 (6.5%)
Belgium	1 (3.2%)
China	1 (3.2%)
France	1 (3.2%)
Switzerland	1 (3.2%)
Taiwan	1 (3.2%)
a n (%)
b Studies with multiple publications counted once (applies to 2 studies with 2 publications).

Comparators

Study Characteristics

Table 8. Selected characteristic of included studies.

Study	N	Arm	ASA PSa	Dementia N (%)b	Agec	MMSEc
HipFx — Randomized Clinical Trial
Marcantonio 2001	64	Std	NR		80.0 (8.0)
	62	Exp			78.0 (8.0)
Shyu 2005	69	Std	NR	0 (0)	77.7 (7.1)
	68	Exp		0 (0)	77.6 (8.3)
Vidan 2005	164	Std	NR	39 (23.8)	82.6 (7.4)
	155	Exp		39 (25.2)	81.1 (7.8)
Shyu 2008 (Shyu 2005)	82	Std	NR	0 (0)	78.9 (7.3)
	80	Exp		0 (0)	77.4 (8.2)
Watne 2014	166	Std	NR	82 (49.4)	85.0 {46-101}
	163	Exp		80 (49.1)	84.0 {55-99}
Prestmo 2015	199	Std	NR	26 (13.1)	83.2 (6.4)
	198	Exp		27 (13.6)	83.4 (5.4)
Zhu 2022	85	Std	1234		81.8
	70	Exp			79.5
GI/Abd — Randomized Clinical Trial
Ommundsen 2018	63	Std	NR	6 (9.5)	78.8 (7.8)
	53	Exp		3 (5.7)	78.2 (7.4)
Various — Randomized Clinical Trial
Hempenius 2013	149	Std	NR		77.6 (7.7)	26.3 (3.9)
	148	Exp			77.5 (6.7)	26.7 (3.0)
Hempenius 2016 (Hempenius 2013)	133	Std	NR		77.4 (7.7)
	127	Exp			77.4 (6.9)
Partridge 2017	105	Std	NR	5 (4.8)	75.5 (6.3)
	104	Exp		2 (1.9)	75.5 (6.6)
HipFx — Nonrandomized Trial
Deschodt 2011	77	Std	NR	18 (23.4)	81.1 (7.2)	7.2 (3.9)
	94	Exp		16 (17.0)	80.4 (7.0)	7.3 (3.9)
HipFx — Before-After/Time Series
Bjorkelund 2010	132	Std	1234	0 (0)	82.0 (7.6)
	131	Exp		0 (0)	81.1 (7.5)
Vochteloo 2011		Std	NR		82.9
	378	Exp			83.7
GI/Abd — Before-After/Time Series
Indrakusuma 2015	222	Std	NR	22 (9.9)	77.0 {73-81}
	221	Exp		27 (12.2)	77.0 {74-82}
Souwer 2018	63	Std	1234		81.4 {74-89}
	86	Exp			80.6 {74-87}
Giannotti 2022	117	Std	NR		82.0 {78-85}	28 {26-29}
	90	Exp			79.0 {76-83}	27 {25-29}
Staiger 2023	54	Std	NR		75.0 {70-81}
	18	Exp			80.0 {72-83}
Cardiac — Before-After/Time Series
Smoor 2023	183	Std	NR	29 (15.8)	76.0 {73-78}
	183	Exp		32 (17.5)	77.0 {73-80}
Neuro — Before-After/Time Series
Adogwa 2017	25	Std	NR		73.0 (4.9)
	100	Exp			73.6 (6.0)
Urol — Before-After/Time Series
Braude 2017	101	Std	NR
	124	Exp
Other Ortho — Before-After/Time Series
Harari 2007	54	Std	NR		75.0 (6.1)
	54	Exp			74.1 (6.2)
Olsson 2014	138	Std	123		66.0 (13.9)
	128	Exp			68.0 (12.0)
Romano 2021	59	Std	123		73.0 {68-77}
	122	Exp			70.0 {64-77}
Various — Before-After/Time Series
Richter 2005	30	Std	123		72.6 (8.3)
	32	Exp			70.9 (6.3)
Bakker 2014	120	Std	NR		76.5 (4.9)	26.6 (3.7)
	121	Exp			76.0 (5.1)	27.3 (2.6)
Ernst 2014	160	Std	NR		68.3 (11.2)
	150	Exp			71.3 (10.6)
Hall 2017	5275	Std	1234		60.3 (13.4)
	3878	Exp			60.3 (13.7)
McDonald 2018	143	Std	NR		71.9 (6.4)
	183	Exp			75.6 (6.8)
Lester 2022	250	Std	NR		82.7 {78-87}
	242	Exp			81.1 {78-86}
GI/Abd — Retrospective Cohort
T-Santabalbina 2019	107	Std	1234	4 (3.7)	75.3 (5.1)
	203	Exp		27 (13.3)	77.5 (4.8)
Cardiac — Retrospective Cohort
Paille 2021	114	Std	NR		81.0 {77-83}
	114	Exp			80.0 {79-82}
Various — Prospective Cohort
Jones 2021	308	Std	234		80.0 (5.0)
	158	Exp			80.0 (5.0)
Exp: expanded preoperative evaluation; Std: standard preoperative evaluation; NR: not reported.
a ASA Physical Status.
b Blank if no information provided.
c Mean Med (SD)[Range]{IQR}.

Evaluation/Intervention Components

Table 9. Components of expanded preoperative evaluation and interventions prompted.

		Assessments								Interventions
Study	ERAS	Generala				Targeteda				Patient Education						Staff
		CGA	Multidisciplinary	Meds/comorbidity	Nutrition	Frailty	Cognitive	Physical function	Psychosocial	Nutrition	Physical activity	Procedure	Social ties	Eexpectations	Palliative care discuss	Meds/comorbidities	Meds Review	Geriatric visits	Multidisciplinary	Nutritional suppl	Treatment plan	Haloperidol prophylaxis	Active delirium screen
HipFx — Randomized Clinical Trial
Marcantonio 2001		◐	◐	◐	◐	◐	◐	◐	◐	◐	◐						◐	◐	●	◐	◐	◐	●
Shyu 2005, 2008		◐	◐	◐	◐	◐	◐	◐	◐		◑							◐	◐		◐
Vidan 2005		◐	◐	◐	◐	◐	◐	◐	◐		◐		◐					◐	◐
Watne 2014		◐	◐	◐	◐	◐	◐	◐	◐	◐	●		◐				◐		◐	◐	◐
Prestmo 2015		◐	◐	◐	◐	◐	◐	◐	◐	◐	◐		◐			◐			◐		◐
Zhu 2022		◐	◐	◐	◐	◐	◐	◐	◐	◐	◐		◐			◐	◐		◐
GI/Abd — Randomized Clinical Trial
Ommundsen 2018	x	◐	◐	◐	◐	●	◐	◐	◐	◐	◐		◐			◐	◐		◐	◐	◐
Various — Randomized Clinical Trial
Hempenius 2013, 2016		◐	◐	◐	◐	●	◐	◐	◐									◐	◐		◐
Partridge 2017		◐	◐	●	◐	◐	◐	◐	◐					◐					◐		◐
HipFx — Nonrandomized Trial
Deschodt 2011		◐	◐	◐	◐	◐	●	●	●								◐		◐	◐	◐
HipFx — Before-After/Time Series
Bjorkelund 2010							◐										◐	◐	◐	◐			●
Vochteloo 2011							◐															◐	●
GI/Abd — Before-After/Time Series
Indrakusuma 2015							◐	◐										◐	◐	◐	◐	◐
Souwer 2018	x		◐	●	●	●	●	◐	◐	◐	◐					◐			◐		◐
Giannotti 2022b	x	●	◐	◐	◐	◐	◐	◐	◐	◐	◐					◐		◐	●
Staiger 2023			◐			◐	◐										◐			◐	◐
Cardiac — Before-After/Time Series
Smoor 2023				●	●	●	●	●	●	◐	◐			◐			◐		◐	◐	◐
Neuro — Before-After/Time Series
Adogwa 2017			◐	◐												◐		◐	◐
Urol — Before-After/Time Series
Braude 2017		◐	◐	◐	◐	◐	◐	◐	◐										◐		◐
Other Ortho — Before-After/Time Series
Harari 2007		◐	◐	◐	◐	◐	◐	◐	◐	◐	◐
Olsson 2014								◐	◐		◐	●	◐	◐							◐
Romano 2021	x		◐	●	◐				◐	◐	◐		◐			◐			◐		◐
Various — Before-After/Time Series
Richter 2005				◑	◐		◐	●	●												◐
Bakker 2014		◐	◐	◐	◐	◐	◐	◐	◐	◐	◐		◐				◐	◐	◐		◐
Ernst 2014						◐								◐	◐				◐		◐
Hall 2017						◐						◐		◐	◐				◐		◐
McDonald 2018	x			◐	◐		◐	◐	◐	◐	◐		◐	◐		◐	◐	◐	◐		◐
Lester 2022			◐	◐	◐		◐	◐		◐	◐						◐	◐	◐		◐
GI/Abd — Retrospective Cohort
T-Santabalbina 2019		◐	◐	◐	◐	◐	◐	◐	◐	◐			◐				◐		●	◐	◐		●
Cardiac — Retrospective Cohort
Paille 2021		◐	◐	◐	◐	◐	◐	◐	◐										◐		◐
Various — Prospective Cohort
Jones 2021					◐	◐	◐	◐			◐						◐		◐		◐
ERAS: enhanced recovery after surgery; CGA: comprehensive geriatric assessment; GI: gastrointestinal; Abd: abdominal; Suppl: supplement; ◐ expanded evaluation only; ● in expanded and standard evaluation arms; ◑ in standard evaluation arms only.
a When a comprehensive geriatric assessment (CGA) was conducted, all components were presumed included.
b Selective comprehensive geriatric assessment in standard arm.

Intervention Frequency

Table 10. Intervention components following expanded screening.

Patient interventions
Intervention	N = 31a
Physical activity	16 (52%)
Nutrition	14 (45%)
Social Ties	10 (32%)
Surgery/recovery expectations	6 (19%)
Procedure	2 (6.5%)
Palliative care discussion	2 (6.5%)
a n (%)

Staff interventions
Intervention	N = 31a
Multidisciplinary	26 (84%)
Treatment Plan	24 (77%)
Geriatric Visits	11 (35%)
Medication Review/Deprescribing	13 (42%)
Nutritional Supplement	9 (29%)
Rx/comorbidities	8 (26%)
Active Delirium Screen	4 (13%)
Haloperidol Prophylaxis	3 (9.7%)
a n (%)

Delirium Incidence

Table 11. Delirium incidence with expanded versus standard preoperative evaluation.

Study	N	Arm	Dementia N (%)	Scale	Day(s)a	Surgery	Incidence Proportion		RR (95% CI)
							N (%)	0 – 100%
Randomized Clinical Trial
Marcantonio 2001	64	Std		CAM	Stay	HipFx	32 (50.0)		—
	62	Exp					20 (32.3)		0.65 (0.42-1.00)
Vidan 2005	164	Std	39 (23.8)	CAM	Stay	HipFx	67 (40.9)		—
	155	Exp	39 (25.2)				53 (34.2)		0.84 (0.63-1.11)
Watne 2014	166	Std	82 (49.4)	CAM	10	HipFx	86 (51.8)		—
	163	Exp	80 (49.1)				80 (49.1)		0.95 (0.76-1.17)
Zhu 2022	85	Std		DSM	Stay	HipFx	27 (31.8)		—
	70	Exp					15 (21.4)		0.67 (0.39-1.16)
Hempenius 2013	133	Std		DOS/DSM	10	Various	19 (14.3)		—
	127	Exp					12 (9.4)		0.66 (0.33-1.31)
Partridge 2017	91	Std	5 (4.8)	unspecified	Stay	Various	22 (24.2)		—
	85	Exp	2 (1.9)				9 (10.6)		0.44 (0.21-0.90)
Before-After/Time Series
Bjorkelund 2010	132	Std	0 (0)	DSM/other	Stay	HipFx	45 (34.1)		—
	131	Exp	0 (0)				29 (22.1)		0.65 (0.44-0.97)
Vochteloo 2011	b	Stdc		DSM	Stay	HipFx	(29.0)		—
	b	Stdd					(23.9)		—
	b	Stde					(27.8)		—
	378	Exp					102 (27.0)		—
Harari 2007	54	Std		unspecified	Stay	Other Ortho	10 (18.5)		—
	54	Exp					3 (5.6)		0.30 (0.09-1.03)
Indrakusuma 2015	222	Std	22 (9.9)	DOS/other	Stay	GI/Abd	27 (12.2)		—
	221	Exp	27 (12.2)				22 (10.0)		0.82 (0.48-1.39)
Bakker 2014	120	Std		CAM	30	Various	16 (13.3)		—
	121	Exp					15 (12.4)		0.93 (0.48-1.79)
Lester 2022	210	Std		CAM	Stay	Various	25 (11.9)		—
	182	Exp					12 (6.6)		0.55 (0.29-1.07)
Adogwa 2017	25	Std		unspecified	Stay	Neuro	4 (16.0)		—
	100	Exp					18 (18.0)		1.12 (0.42-3.03)
Retrospective Cohort
T-Santabalbina 2019	107	Std	4 (3.7)	CAM	Stay	GI/Abd	31 (29.0)		—
	203	Exp	27 (13.3)				23 (11.3)		0.39 (0.24-0.64)
Paille 2021	114	Std		unspecified	Stay	Cardiac	18 (15.8)		—
	114	Exp					13 (11.4)		0.72 (0.37-1.40)
RR: risk ratio; CAM: Confusion Assessment Method; DI: Delirium Index; DRS: Delirium Rating Scale; DOS: delirium observation screening; DSM: Diagnostic and Statistical Manual of Mental Disorders; NR: not reported; HipFx: hip fracture; GI/Abd: gastrointestinal or abdominal.
a Day(s) over which incidence proportion assessed. Stay indicates duration of hospitalization.
b N = 611 for the 3 years of standard evaluation (2005-2007); outcomes reported by year separately.
c 2005.
d 2006.
e 2007.

Pooled

Randomized

Figure 1. Delirium incidence following expanded compared with standard preoperative evaluation in randomized clinical trials.

RR: risk ratio; D1: bias arising from the randomization process; D2: bias due to deviations from intended interventions; D3: bias due to missing outcome data; D4: bias in measurement of the outcome; D5: bias in selection of the reported result: All: overall risk of bias.
Risk of bias ratings: low +, some concerns ?, high – .
Too few studies to adequately examine small study effects, but funnel suggests potential exists.

Meta-analysis methods detail.

- Mantel-Haenszel method (common effect model)
- Inverse variance method (random effects model)
- Restricted maximum-likelihood estimator for τ²
- Q-Profile method for confidence interval of τ² and τ
- Hartung-Knapp adjustment for random effects model (df = 5)
- Hartung-Knapp prediction interval (df = 4)

Figure 2. Delirium incidence RCTs — small study effects.

Figure 3. Delirium incidence in randomized clinical trials — risk difference per 100.

Figure 4. Control arm/baseline risk (standard evaluation) and risk ratios.

No suggestion for dependence of risk ratio on baseline risk.

Figure 5. Delirium incidence summary risk of bias in RCTs (weighted).

Nonrandomized

Figure 6. Delirium incidence following expanded compared with standard preoperative evaluation in nonrandomized studies.

RR: risk ratio; D1: Bias due to confounding; D2: Bias in selection of participants into the study; D3: Bias in classification of interventions; D4: Bias due to deviations from intended interventions; D5: Bias due to missing data; D6: Bias in measurement of outcomes; D7: Bias in selection of reported results; All: overall risk of bias.
Risk of bias ratings: low ++, moderate +, serious -, critical - - ; NI: no information.
Including Vochteloo 2011 assuming effectively equal numbers of participants studied each year, obtained RR 0.70 (95% CI, 0.53-0.95; PI, 0.35–1.42).
Pooling odds ratios using the adjusted result from Tarazona-Santabalbina 2019 yielded an OR 0.58 (95% CI, 0.39–0.88) versus using including the unadjusted data OR 0.58 (95%, 0.40–0.84).

Figure 7. Delirium incidence nonrandomized studies — small study effects.

Figure 8. Delirium incidence in nonrandomized studies — risk difference per 100.

RR: risk ratio; D1: Bias due to confounding; D2: Bias in selection of participants into the study; D3: Bias in classification of interventions; D4: Bias due to deviations from intended interventions; D5: Bias due to missing data; D6: Bias in measurement of outcomes; D7: Bias in selection of reported results; All: overall risk of bias.
Risk of bias ratings: low ++, moderate +, serious -, critical - - ; NI: no information.

Figure 9. Control arm/baseline risk (standard evaluation) and risk ratios — nonrandomized designs.

Figure 10. Delirium incidence summary risk of bias in nonrandomized studies (weighted).

Neurocognitive Disorder
  <30 days

Table 12. Neurocognitive disorder <30 days incidence and ascertainment (expanded versus standard preoperative evaluation; randomized and nonrandomized designs).

Study	N	Drug	Preop	Instrument				Neurocognitive Disorder <30 days
			MMSE	MMSE	DST	MoCA	Other	N (%)	0 — 100%	RR (95% CI)
Before-After/Time Series — Various Procedures
Bakker 2014	84	Std	26.6 (3.7)	✓				16 (19.0)		—
	96	Exp	27.3 (2.6)					13 (13.5)		0.71 (0.36-1.39)
Mini-Mental State Exam; DST: Digit Span Test; MoCA: Montreal Cognitive Assessment; RR: risk ratio.

Neurocognitive Disorder
  30 days to 1 year

No studies

Physical Function

Table 13. Physical functional status for expanded versus standard preoperative evaluation (randomized* and nonrandomized designs).

Study	N	Arm	Agea	Scale	Range	Days	Ratinga	SMD (95% CI)	Surgery
<30 days
Deschodt 2011	77	Std	81.1 (7.2)	Katz Index	0→18	8	12.9 (2.5)		HipFx
	94	Exp	80.4 (7.0)				12.0 (2.7)	-0.34 (-0.65 to -0.04)
Zhu 2022*	85	Std	81.8	Barthel Index	0→100	21	51.7		HipFx
	70	Exp	79.5				50.5	-0.10 (-0.42 to 0.22)
Bakker 2014	80	Std	76.5 (4.9)	GARS	44→11	8	b		Various
	98	Exp	76.0 (5.1)				b	0.29 (-0.01 to 0.59)c
Hempenius 2016*	133	Std	77.4 (7.7)	SF-36 physical	0→100	10	49.3 (7.0)		Various
	127	Exp	77.4 (6.9)				48.4 (9.1)	-0.12 (-0.36 to 0.13)
30-90 days
Prestmo 2015*	169	Std	83.2 (6.4)	Barthel Index	0→20	30	14.2 (3.8)		HipFx
	179	Exp	83.4 (5.4)				14.5 (3.7)	0.08 (-0.13 to 0.29)
Shyu 2005*	69	Std	77.7 (7.1)	SF-36 physical	0→100	30	18.8 (21.2)		HipFx
	68	Exp	77.6 (8.3)				23.3 (20.4)	0.22 (-0.12 to 0.55)
Shyu 2005*	69	Std	77.7 (7.1)	SF-36 physical	0→100	90	28.2 (27.2)		HipFx
	68	Exp	77.6 (8.3)				48.4 (30.4)	0.69 (0.35 to 1.04)
Bakker 2014	62	Std	76.5 (4.9)	GARS	44→11	90	b		Various
	81	Exp	76.0 (5.1)				b	-0.36 (-0.69 to -0.03)c
Richter 2005	30	Std	72.6 (8.3)	SF-36 physical	0→100	42	37.6 (7.5)		Various
	32	Exp	70.9 (6.3)				39.0 (8.3)	0.17 (-0.32 to 0.67)
>90 days
Smoor 2023	183	Std	76.0 {73-78}	SF-12 physical	0→100	120	34 [0-43]		Cardiac
	183	Exp	77.0 {73-80}				36 [32-38]	0.61 (0.40 to 0.82)
Prestmo 2015*	165	Std	83.2 (6.4)	Barthel Index	0→20	120	15.3 (3.7)		HipFx
	168	Exp	83.4 (5.4)				16.3 (3.7)	0.27 (0.05 to 0.49)
Watne 2014*	120	Std	85.0 {46-101}	Barthel Index	0→20	120	16 [12-20]		HipFx
	119	Exp	84.0 {55-99}				17 [10-20]	-0.09 (-0.34 to 0.16)
Watne 2014*	93	Std	85.0 {46-101}	Barthel Index	0→20	365	16 [11-19]		HipFx
	97	Exp	84.0 {55-99}				17 [10-19]	-0.06 (-0.34 to 0.23)
Richter 2005	30	Std	72.6 (8.3)	SF-36 physical	0→100	180	49.2 (10.4)		Various
	32	Exp	70.9 (6.3)				45.3 (10.9)	-0.36 (-0.86 to 0.14)
SMD: standardized mean difference; GARS: Groningen Activity Restriction Scale.
* Randomized clinical trial.
a Mean Med (SD)[Range]{IQR}.
b Study reported only difference scores.
c For scale reverse to be consistent with other studies.

Pooled

Randomized

Figure 11. Pooled results for physical functional status for expanded versus standard preoperative evaluation from randomized clinical trials (higher is better).

Multilevel model fitted accounting for studies reporting at more than one time point.

Meta-analysis methods detail.

- Inverse variance method (three-level model)
- Restricted maximum-likelihood estimator for τ²
- Profile-Likelihood method for confidence interval of τ² and τ
- Hedges’ g (bias corrected standardised mean difference; using exact formulae)

Figure 12. SMDs over time in randomized clinical trials.

  

Nonrandomized

Figure 13. Pooled results for physical functional status for expanded versus standard preoperative evaluation from nonrandomized studies (higher is better).

Multilevel model fitted accounting for reporting at more than one time point.

Meta-analysis methods detail.

- Inverse variance method (three-level model)
- Restricted maximum-likelihood estimator for τ²
- Profile-Likelihood method for confidence interval of τ² and τ
- Hedges’ g (bias corrected standardised mean difference; using exact formulae)

Figure 14. SMDs over time in nonrandomized studies.

Complications

Table 14. Complications reported in expanded versus standard preoperative evaluation — cardiac, pulmonary, and acute kidney injury (randomized and nonrandomized designs).

Study	N	Arm	Agea	N (%)	0 – 100%	RD (95% CI)	Surgery
MI – Randomized Clinical Trial
Vidan 2005	164	Std	82.6 (7.4)	1 (0.6)		—	HipFx
	155	Exp	81.1 (7.8)	0 (0)		-0.6% (-2.3, 1.1)
MI – Before-After/Time Series
Bjorkelund 2010	132	Std	82.0 (7.6)	5 (3.8)		—	HipFx
	131	Exp	81.1 (7.5)	3 (2.3)		-1.5% (-5.6, 2.6)
Adogwa 2017	25	Std	73.0 (4.9)	1 (4.0)		—	Neuro
	100	Exp	73.6 (6.0)	1 (1.0)		-3.0% (-10.9, 4.9)
Lester 2022	250	Std	82.7 {78-87}	0 (0)		—	Various
	242	Exp	81.1 {78-86}	2 (0.8)		0.8% (-0.6, 2.2)
McDonald 2018	143	Std	71.9 (6.4)	5 (3.5)		—	Various
	183	Exp	75.6 (6.8)	3 (1.6)		-1.9% (-5.4, 1.7)
Cardiac Arrest – Randomized Clinical Trial
Partridge 2017	91	Std	75.5 (6.3)	5 (5.5)		—	Various
	85	Exp	75.5 (6.6)	1 (1.2)		-4.3% (-9.5, 0.9)
Cardiac Arrest – Before-After/Time Series
McDonald 2018	143	Std	71.9 (6.4)	2 (1.4)		—	Various
	183	Exp	75.6 (6.8)	1 (0.5)		-0.9% (-3.1, 1.3)
Other Cardiac – Randomized Clinical Trial
Watne 2014b	166	Std	85.0 {46-101}	19 (11.4)		—	HipFx
	163	Exp	84.0 {55-99}	22 (13.5)		2.1% (-5.1, 9.2)
Hempenius 2013c	133	Std	77.6 (7.7)	37 (27.8)		—	Various
	127	Exp	77.5 (6.7)	40 (31.5)		3.7% (-7.4, 14.8)
Partridge 2017d	91	Std	75.5 (6.3)	25 (27.5)		—	Various
	85	Exp	75.5 (6.6)	7 (8.2)		-19.2% (-30.1, -8.4)
Other Cardiac – Before-After/Time Series
Giannotti 2022b	117	Std	82.0 {78-85}	25 (21.4)		—	GI/Abd
	90	Exp	79.0 {76-83}	16 (17.8)		-3.6% (-14.4, 7.3)
Indrakusuma 2015b	222	Std	77.0 {73-81}	28 (12.6)		—	GI/Abd
	221	Exp	77.0 {74-82}	32 (14.5)		1.9% (-4.5, 8.2)
Souwer 2018b	63	Std	81.4 {74-89}	5 (7.9)		—	GI/Abd
	86	Exp	80.6 {74-87}	0 (0)		-7.9% (-15.0, -0.9)
Bjorkelund 2010e	132	Std	82.0 (7.6)	11 (8.3)		—	HipFx
	131	Exp	81.1 (7.5)	7 (5.3)		-3.0% (-9.1, 3.1)
McDonald 2018f	143	Std	71.9 (6.4)	45 (31.5)		—	Various
	183	Exp	75.6 (6.8)	40 (21.9)		-9.6% (-19.3, 0.1)
Acute Kidney Injury – Randomized Clinical Trial
Watne 2014	166	Std	85.0 {46-101}	2 (1.2)		—	HipFx
	163	Exp	84.0 {55-99}	6 (3.7)		2.5% (-0.9, 5.8)
Hempenius 2013	133	Std	77.6 (7.7)	2 (1.5)		—	Various
	127	Exp	77.5 (6.7)	5 (3.9)		2.4% (-1.5, 6.4)
Acute Kidney Injury – Before-After/Time Series
Giannotti 2022	117	Std	82.0 {78-85}	41 (35.0)		—	GI/Abd
	90	Exp	79.0 {76-83}	25 (27.8)		-7.3% (-19.9, 5.4)
Bjorkelund 2010	132	Std	82.0 (7.6)	2 (1.5)		—	HipFx
	131	Exp	81.1 (7.5)	1 (0.8)		-0.8% (-3.3, 1.8)
McDonald 2018	143	Std	71.9 (6.4)	13 (9.1)		—	Various
	183	Exp	75.6 (6.8)	15 (8.2)		-0.9% (-7.1, 5.3)
Pulmonary – Randomized Clinical Trial
Watne 2014b	166	Std	85.0 {46-101}	13 (7.8)		—	HipFx
	163	Exp	84.0 {55-99}	21 (12.9)		5.1% (-1.5, 11.6)
Hempenius 2013b	133	Std	77.6 (7.7)	27 (20.3)		—	Various
	127	Exp	77.5 (6.7)	31 (24.4)		4.1% (-6.0, 14.2)
Partridge 2017g	91	Std	75.5 (6.3)	13 (14.3)		—	Various
	85	Exp	75.5 (6.6)	8 (9.4)		-4.9% (-14.4, 4.6)
Pulmonary – Retrospective Cohort
Paille 2021h	114	Std	81.0 {77-83}	37 (32.5)		—	Cardiac
	114	Exp	80.0 {79-82}	32 (28.1)		-4.4% (-16.3, 7.5)
Pneumonia – Randomized Clinical Trial
Vidan 2005	164	Std	82.6 (7.4)	6 (3.7)		—	HipFx
	155	Exp	81.1 (7.8)	6 (3.9)		0.2% (-4.0, 4.4)
Partridge 2017	91	Std	75.5 (6.3)	12 (13.2)		—	Various
	85	Exp	75.5 (6.6)	8 (9.4)		-3.8% (-13.1, 5.5)
Pneumonia – Before-After/Time Series
Giannotti 2022	117	Std	82.0 {78-85}	26 (22.2)		—	GI/Abd
	90	Exp	79.0 {76-83}	10 (11.1)		-11.1% (-21.1, -1.2)
Indrakusuma 2015	222	Std	77.0 {73-81}	31 (14.0)		—	GI/Abd
	221	Exp	77.0 {74-82}	37 (16.7)		2.8% (-3.9, 9.5)
Bjorkelund 2010	132	Std	82.0 (7.6)	3 (2.3)		—	HipFx
	131	Exp	81.1 (7.5)	6 (4.6)		2.3% (-2.1, 6.7)
Adogwa 2017	25	Std	73.0 (4.9)	1 (4.0)		—	Neuro
	100	Exp	73.6 (6.0)	5 (5.0)		1.0% (-7.8, 9.8)
Harari 2007	54	Std	75.0 (6.1)	11 (20.4)		—	Other Ortho
	54	Exp	74.1 (6.2)	2 (3.7)		-16.7% (-28.5, -4.8)
Lester 2022	250	Std	82.7 {78-87}	2 (0.8)		—	Various
	242	Exp	81.1 {78-86}	1 (0.4)		-0.4% (-1.8, 1.0)
McDonald 2018	143	Std	71.9 (6.4)	2 (1.4)		—	Various
	183	Exp	75.6 (6.8)	3 (1.6)		0.2% (-2.4, 2.9)
Respiratory Failure – Before-After/Time Series
McDonald 2018	143	Std	71.9 (6.4)	21 (14.7)		—	Various
	183	Exp	75.6 (6.8)	16 (8.7)		-5.9% (-13.0, 1.2)
Ventilator >48hr – Before-After/Time Series
McDonald 2018	143	Std	71.9 (6.4)	2 (1.4)		—	Various
	183	Exp	75.6 (6.8)	0 (0)		-1.4% (-3.7, 0.9)
PE – Before-After/Time Series
Bjorkelund 2010	132	Std	82.0 (7.6)	2 (1.5)		—	HipFx
	131	Exp	81.1 (7.5)	2 (1.5)		0.0% (-2.9, 3.0)
Adogwa 2017	25	Std	73.0 (4.9)	0 (0)		—	Neuro
	100	Exp	73.6 (6.0)	2 (2.0)		2.0% (-4.1, 8.1)
Harari 2007	54	Std	75.0 (6.1)	2 (3.7)		—	Other Ortho
	54	Exp	74.1 (6.2)	0 (0)		-3.7% (-9.8, 2.3)
McDonald 2018	143	Std	71.9 (6.4)	1 (0.7)		—	Various
	183	Exp	75.6 (6.8)	2 (1.1)		0.4% (-1.6, 2.4)
Acute Kidney Injury – Retrospective Cohort
Paille 2021	114	Std	81.0 {77-83}	44 (38.6)		—	Cardiac
	114	Exp	80.0 {79-82}	33 (28.9)		-9.6% (-21.9, 2.6)
RD: risk difference; MI: myocardial infarction; GI: gastrointestinal; Abd: abdominal; Ortho: orthopedic; Neuro: neurologic.
a Mean Med (SD)[Range]{IQR}.
b Unspecified.
c Arrhythmia, cardiac failure.
d Acute coronary syndrome, heart failure, tachyarrhythmia, or bradyarrhythmia.
e Cardiac failure.
f MI, cardiac arrest, ventricular fibrillation, dysrhythmia, or heart failure.
g Pneumonia, infectious exacerbation of chronic obstructive pulmonary disease (COPD).
h Pulmonary embolism or pneumothorax.

Pooled

Myocardial Infarction

  

Figure 15. Risk ratio for myocardial infarction (randomized and nonrandomized designs).

Cardiac Arrest

  

Figure 16. Risk ratio for cardiac arrest (randomized and nonrandomized designs).

Acute Kidney Injury

  

Figure 17. Risk ratio for renal complications (expanded versus standard preoperative evaluation; randomized clinical trials).

Pneumonia

  

Figure 18. Risk ratio for pneumonia (randomized and nonrandomized designs).

Pulmonary Embolism

  

Figure 19. Risk ratio for pneumonia (randomized and nonrandomized designs).

Patient Satisfaction

Table 15. Patient satisfaction according to expanded or standard preoperative evaluation.

Study	N	Anesth	ASA	Agea	N (%)	0 – 100%	RD (95% CI)
			PS
Various (pelvic floor)
Richter 2005	30	Std	123	72.6 (8.3)	29 (96.7)b		—
	32	Exp		70.9 (6.3)	32 (100)b		3.3% (-5.3, 12.0)
Std: standard evaluation; Exp: expanded evaluation; ASA PS: ASA Physical Status; RD: risk difference.
a Mean (SD).
b High satisfaction.

Length of Stay

Table 16. Length of stay according to procedure classification and type of preoperative evaluation.

Study	N	Arm	PSa	Ageb	LOSb	0 – 25 days	Country
Randomized Clinical Trial - HipFx
Marcantonio 2001	64	Std	NR	80.0 (8.0)	5.0 {3-7}		USA
	62	Exp	NR	78.0 (8.0)	5.0 {3-7}
Shyu 2005	69	Std	NR	77.7 (7.1)	10.2 (6.5)		Taiwan
	68	Exp	NR	77.6 (8.3)	10.1 (3.7)
Vidan 2005	164	Std	NR	82.6 (7.4)	18.0 {13-24}		Spain
	155	Exp	NR	81.1 (7.8)	16.0 {13-19}
Watne 2014	166	Std	NR	85.0 {46-101}	8.0 {5-11}		Norway
	163	Exp	NR	84.0 {55-99}	11.0 {8-15}
Prestmo 2015	199	Std	NR	83.2 (6.4)	11.0 (0.5)		Norway
	198	Exp	NR	83.4 (5.4)	12.6 (0.4)
Zhu 2022	85	Std	1234	81.8	23.6		China
	70	Exp	1234	79.5	20.8
Nonrandomized Trial - HipFx
Deschodt 2011	77	Std	NR	81.1 (7.2)	12.4 (8.5)		Belgium
	94	Exp	NR	80.4 (7.0)	11.1 (5.1)
Before-After/Time Series - Other Ortho
Harari 2007	54	Std	NR	75.0 (6.1)	15.8 (13.2)		UK
	54	Exp	NR	74.1 (6.2)	11.5 (5.2)
Olsson 2014	138	Std	123	66.0 (13.9)	5.3 (2.2)		Sweden
	128	Exp	123	68.0 (12.0)	7.0 (5.0)
Romano 2021	59	Std	123	73.0 {68-77}	8.0 {8-10}		Italy
	122	Exp	123	70.0 {64-77}	5.0 {4-6}
Randomized Clinical Trial - GI/Abd
Ommundsen 2018	63	Std	NR	78.8 (7.8)	8.0		Norway
	53	Exp	NR	78.2 (7.4)	8.0
Before-After/Time Series - GI/Abd
Indrakusuma 2015	222	Std	NR	77.0 {73-81}	9.0 {7-14}		Netherlands
	221	Exp	NR	77.0 {74-82}	7.0 {5-12}
Giannotti 2022	117	Std	NR	82.0 {78-85}	9.0 {8-14}		Italy
	90	Exp	NR	79.0 {76-83}	9.0 {7-14}
Staiger 2023	54	Std	NR	75.0 {70-81}	6.0 {4-8}		Switzerland
	18	Exp	NR	80.0 {72-83}	4.0 {3-7}
Retrospective Cohort - GI/Abd
T-Santabalbina 2019	107	Std	1234	75.3 (5.1)	9.0 {8-13}		Spain
	203	Exp	1234	77.5 (4.8)	11.0 {9-17}
Retrospective Cohort - Cardiac
Paille 2021	114	Std	NR	81.0 {77-83}	13.0 {11-18}		France
	114	Exp	NR	80.0 {79-82}	12.0 {10-18}
Before-After/Time Series - Neuro
Adogwa 2017	25	Std	NR	73.0 (4.9)	8.7 (6.1)		USA
	100	Exp	NR	73.6 (6.0)	6.1 (5.7)
Before-After/Time Series - Urol
Braude 2017	101	Std	NR		4.9 (4.4)		UK
	124	Exp	NR		4.0 (3.5)
Randomized Clinical Trial - Various
Hempenius 2013	149	Std	NR	77.6 (7.7)	8.0 [1-44]		Netherlands
	148	Exp	NR	77.5 (6.7)	8.0 [1-135]
Partridge 2017	105	Std	NR	75.5 (6.3)	5.5c		UK
	104	Exp	NR	75.5 (6.6)	3.3c
Before-After/Time Series - Various
Bakker 2014	120	Std	NR	76.5 (4.9)	8.3 (8.4)		Netherlands
	121	Exp	NR	76.0 (5.1)	8.3 (7.0)
McDonald 2018	143	Std	NR	71.9 (6.4)	6.0 [1-60]		USA
	183	Exp	NR	75.6 (6.8)	4.0 [1-75]
Lester 2022	250	Std	NR	82.7 {78-87}	3.0 {2-6}		USA
	242	Exp	NR	81.1 {78-86}	3.0 {2-6}
Prospective Cohort - Various
Jones 2021	308	Std	234	80.0 (5.0)	8.8 (11.8)		USA
	158	Exp	234	80.0 (5.0)	5.4 (4.8)
NR: not reported
a ASA Physical Status.
b Mean Med (SD)[Range]{IQR}.
c Geometric mean.

Pooled

Randomized

Figure 20. Mean difference in lengths of stay in randomized clinical trials.

Partridge 2017 geometric means reported.
Ommundsen 2018 reported only median and between-group p-value and was excluded.

Nonrandomized

Figure 21. Mean difference in lengths of stay in nonrandomized studies.

When the mean or standard deviation were not reported, they were imputed from from the median, interquartile range, and/or range.

Discharge Location

Table 17. Discharge location in studies comparing expanded with standard preoperative assessments.

Study	N	Arm	Agea	Country	Discharge to Institution		RR (95% CI)
					N (%)	0 — 100%
Randomized Clinical Trial — HipFx
Marcantonio 2001	64	Std	80.0 (8.0)	USA	56 (87.5)
	62	Exp	78.0 (8.0)		57 (91.9)		1.05 (0.93-1.18)
Prestmo 2015	187	Std	83.2 (6.4)	Norway	167 (89.3)
	191	Exp	83.4 (5.4)		143 (74.9)		0.84 (0.76-0.92)
Nonrandomized Trial — HipFx
Deschodt 2011	77	Std	81.1 (7.2)	Belgium	26 (33.8)
	94	Exp	80.4 (7.0)		30 (31.9)		0.95 (0.61-1.45)
Before-After/Time Series — Other Ortho
Romano 2021	59	Std	73.0 {68-77}	Italy	57 (96.6)
	122	Exp	70.0 {64-77}		45 (36.9)		0.38 (0.30-0.48)
Randomized Clinical Trial — GI/Abd
Ommundsen 2018	63	Std	78.8 (7.8)	Norway	25 (39.7)
	53	Exp	78.2 (7.4)		15 (28.3)		0.71 (0.42-1.21)
Retrospective Cohort — Cardiac
Paille 2021	114	Std	81.0 {77-83}	France	60 (52.6)
	114	Exp	80.0 {79-82}		57 (50.0)		0.95 (0.74-1.22)
Before-After/Time Series — Neuro
Adogwa 2017	25	Std	73.0 (4.9)	USA	19 (76.0)
	100	Exp	73.6 (6.0)		46 (46.0)		0.61 (0.45-0.82)
Before-After/Time Series — Various
Lester 2022	250	Std	82.7 {78-87}	USA	104 (41.6)
	242	Exp	81.1 {78-86}		98 (40.5)		0.97 (0.79-1.20)
McDonald 2018	143	Std	71.9 (6.4)	USA	70 (49.0)
	183	Exp	75.6 (6.8)		69 (37.7)		0.77 (0.60-0.99)
Randomized Clinical Trial — Various
Hempenius 2013	110	Std	77.6 (7.7)	Netherlands	23 (20.9)
	113	Exp	77.5 (6.7)		37 (32.7)		1.57 (1.00-2.45)
Exp: expanded preoperative evaluation; Std: standard preoperative evaluation; RR: risk ratio; Various: more that one procedure category.
a Mean Med (SD)[Range]{IQR}.

Pooled

Figure 22. Pooled comparison of discharge location in randomized and nonrandomized designs.

Meta-analysis methods detail.

- Mantel-Haenszel method (common effect model)
- Inverse variance method (random effects model)
- Restricted maximum-likelihood estimator for τ²
- Q-Profile method for confidence interval of τ² and τ
- Prediction interval based on t-distribution (df = 8)

Mortality

Table 18. Reported mortality in randomized clinical trials.

Study	N	Arm	Surgery	ASA	Agea	Mortality		RD (95% CI)
				PS		N (%)	0 - 100%
Hospital
Vidan 2005	164	Std	HipFx	NR	82.6 (7.4)	9 (5.5)		—
	155	Exp			81.1 (7.8)	1 (0.6)		-4.8% (-8.5, -1.1)
Watne 2014	166	Std	HipFx	NR	85.0 {46-101}	3 (1.8)		—
	163	Exp			84.0 {55-99}	6 (3.7)		1.9% (-1.7, 5.4)
Hempenius 2013	133	Std	Various	NR	77.6 (7.7)	4 (3.0)		—
	127	Exp			77.5 (6.7)	10 (7.9)		4.9% (-0.6, 10.4)
30-day
Shyu 2005	63	Std	HipFx	NR	77.7 (7.1)	0 (0)		—
	63	Exp			77.6 (8.3)	0 (0)		0.0% (-3.1, 3.1)
Ommundsen 2018	63	Std	GI/Abd	NR	78.8 (7.8)	3 (4.8)		—
	53	Exp			78.2 (7.4)	2 (3.8)		-1.0% (-8.3, 6.4)
90-day
Shyu 2005	63	Std	HipFx	NR	77.7 (7.1)	1 (1.6)		—
	63	Exp			77.6 (8.3)	0 (0)		-1.6% (-5.9, 2.7)
Ommundsen 2018	63	Std	GI/Abd	NR	78.8 (7.8)	4 (6.3)		—
	53	Exp			78.2 (7.4)	3 (5.7)		-0.7% (-9.3, 8.0)
Hempenius 2016	133	Std	Various	NR	77.4 (7.7)	9 (6.8)		—
	127	Exp			77.4 (6.9)	17 (13.4)		6.6% (-0.7, 13.9)
1-year
Vidan 2005	164	Std	HipFx	NR	82.6 (7.4)	42 (25.6)		—
	155	Exp			81.1 (7.8)	29 (18.7)		-6.9% (-16.0, 2.2)
Shyu 2008	62	Std	HipFx	NR	78.9 (7.3)	15 (24.2)		—
	60	Exp			77.4 (8.2)	13 (21.7)		-2.5% (-17.4, 12.4)
ASA PS: American Society of Anesthesiologists Physical Status; Exp: expanded; Std: standard; NR: not reported; RD: risk difference.; GI: gastrointestinal; Abd: abdominal (includes hepatic); Various: more that four procedures.
a Mean Med (SD)[Range]{IQR}.

Table 19. Reported mortality in nonrandomized designs (all retrospective cohort studies).

Study	N	Arm	Surgery	ASA	Agea	Mortality		RD (95% CI)
				PS		N (%)	0 - 100%
Hospital
Deschodt 2011	77	Std	HipFx	NR	81.1 (7.2)	0 (0)		—
	94	Exp			80.4 (7.0)	1 (1.1)		1.1% (-2.0, 4.1)
T-Santabalbina 2019	107	Std	GI/Abd	1234	75.3 (5.1)	4 (3.7)		—
	203	Exp			77.5 (4.8)	8 (3.9)		0.2% (-4.3, 4.7)
Staiger 2023	54	Std	GI/Abd	NR	75.0 {70-81}	2 (3.7)		—
	18	Exp			80.0 {72-83}	0 (0)		-3.7% (-12.8, 5.4)
Paille 2021	114	Std	Cardiac	NR	81.0 {77-83}	7 (6.1)		—
	114	Exp			80.0 {79-82}	3 (2.6)		-3.5% (-8.8, 1.8)
McDonald 2018	143	Std	Various	NR	71.9 (6.4)	0 (0)		—
	183	Exp			75.6 (6.8)	1 (0.5)		0.5% (-1.1, 2.2)
30-day
Bjorkelund 2010	132	Std	HipFx	1234	82.0 (7.6)	6 (4.5)		—
	131	Exp			81.1 (7.5)	5 (3.8)		-0.7% (-5.6, 4.1)
Harari 2007	54	Std	Other Ortho	NR	75.0 (6.1)	1 (1.9)		—
	54	Exp			74.1 (6.2)	0 (0)		-1.9% (-6.8, 3.1)
Indrakusuma 2015	222	Std	GI/Abd	NR	77.0 {73-81}	17 (7.7)		—
	221	Exp			77.0 {74-82}	14 (6.3)		-1.3% (-6.1, 3.4)
Souwer 2018	63	Std	GI/Abd	1234	81.4 {74-89}	2 (3.2)		—
	86	Exp			80.6 {74-87}	2 (2.3)		-0.8% (-6.2, 4.5)
T-Santabalbina 2019	107	Std	GI/Abd	1234	75.3 (5.1)	5 (4.7)		—
	203	Exp			77.5 (4.8)	9 (4.4)		-0.2% (-5.1, 4.7)
Giannotti 2022	117	Std	GI/Abd	NR	82.0 {78-85}	9 (7.7)		—
	90	Exp			79.0 {76-83}	3 (3.3)		-4.4% (-10.4, 1.7)
Ernst 2014	160	Std	Various	NR	68.3 (11.2)	51 (31.9)		—
	150	Exp			71.3 (10.6)	32 (21.3)		-10.5% (-20.3, -0.8)
Hall 2017	5,275	Std	Various	1234	60.3 (13.4)	84 (1.6)		—
	3,878	Exp			60.3 (13.7)	26 (0.7)		-0.9% (-1.3, -0.5)
Jones 2021	308	Std	Various	234	80.0 (5.0)	12 (3.9)		—
	158	Exp			80.0 (5.0)	4 (2.5)		-1.4% (-4.6, 1.9)
Lester 2022	250	Std	Various	NR	82.7 {78-87}	6 (2.4)		—
	242	Exp			81.1 {78-86}	10 (4.1)		1.7% (-1.4, 4.9)
Braude 2017	101	Std	Urol	NR		3 (3.0)		—
	124	Exp				0 (0)		-3.0% (-6.7, 0.7)
Adogwa 2017	25	Std	Neuro	NR	73.0 (4.9)	0 (0)		—
	100	Exp			73.6 (6.0)	0 (0)		0.0% (-5.5, 5.5)
90-day
Giannotti 2022	117	Std	GI/Abd	NR	82.0 {78-85}	12 (10.3)		—
	90	Exp			79.0 {76-83}	9 (10.0)		-0.3% (-8.5, 8.0)
1-year
Souwer 2018	63	Std	GI/Abd	1234	81.4 {74-89}	7 (11.1)		—
	86	Exp			80.6 {74-87}	3 (3.5)		-7.6% (-16.3, 1.1)
T-Santabalbina 2019	107	Std	GI/Abd	1234	75.3 (5.1)	10 (9.3)		—
	203	Exp			77.5 (4.8)	23 (11.3)		2.0% (-5.0, 9.0)
Giannotti 2022	117	Std	GI/Abd	NR	82.0 {78-85}	16 (13.7)		—
	90	Exp			79.0 {76-83}	17 (18.9)		5.2% (-5.0, 15.4)
Ernst 2014	160	Std	Various	NR	68.3 (11.2)	126 (78.8)		—
	150	Exp			71.3 (10.6)	99 (66.0)		-12.7% (-22.6, -2.9)
Hall 2017	5,275	Std	Various	1234	60.3 (13.4)	320 (6.1)		—
	2,781	Exp			60.3 (13.7)	78 (2.8)		-3.3% (-4.2, -2.4)
ASA PS: American Society of Anesthesiologists Physical Status; RD: risk difference; GI: gastrointestinal; Abd: abdominal (includes hepatic); Various: more that one procedure category.
a Mean Med (SD)[Range]{IQR}.

Pooled

Randomized

Figure 23. Risk ratio for hospital or 30-day mortality in randomized clinical trials.

  

Figure 24. Risk ratio for 1-year mortality in randomized clinical trials.

  

Nonrandomized

Figure 25. Risk ratio for hospital or 30-day mortality in nonrandomized studies.

  

Figure 26. Risk ratio for 1-year mortality in nonrandomized studies.

Risk of Bias

Randomized

Figure 27. Summary risk of bias assessment for randomized clinical trials (expanded preoperative evaluation).

Figure 28. Risk of bias assessments for randomized clinical trials (expanded preoperative evaluation).

Nonrandomized

Figure 29. Summary risk of bias assessment for nonrandomized studies (expanded preoperative evaluation).

Figure 30. Risk of bias assessments for nonrandomized studies (expanded preoperative evaluation).

References

1.

Adogwa O, Elsamadicy AA, Vuong VD, Moreno J, Cheng J, Karikari IO, Bagley CA: Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: A prospective single-institution experience. J Neurosurg Spine 2017; 27:670–5

2.

Bakker FC, Persoon A, Bredie SJH, Haren-Willems J van, Leferink VJ, Noyez L, Schoon Y, Olde Rikkert MGM: The CareWell in hospital program to improve the quality of care for frail elderly inpatients: Results of a before-after study with focus on surgical patients. Am J Surg 2014; 208:735–46

3.

Bjorkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D: Reducing delirium in elderly patients with hip fracture: A multi-factorial intervention study. Acta Anaesthesiol Scand 2010; 54:678–88

4.

Braude P, Goodman A, Elias T, Babic-Illman G, Challacombe B, Harari D, Dhesi JK: Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of older people undergoing surgery (POPS)-urology. BJU Int 2017; 120:123–9

5.

Deschodt M, Braes T Fau - Broos P, Broos P Fau - Sermon A, Sermon A Fau - Boonen S, Boonen S Fau - Flamaing J, Flamaing J Fau - Milisen K, Milisen K: Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: A controlled trial 2011

6.

Ernst KF, Hall DE, Schmid KK, Seever G, Lavedan P, Lynch TG, Johanning JM: Surgical palliative care consultations over time in relationship to systemwide frailty screening. JAMA Surg 2014; 149:1121–6

7.

Giannotti C, Massobrio A, Carmisciano L, Signori A, Napolitano A, Pertile D, Soriero D, Muzyka M, Tagliafico L, Casabella A, Cea M, Caffa I, Ballestrero A, Murialdo R, Laudisio A, Incalzi RA, Scabini S, Monacelli F, Nencioni A: Effect of geriatric comanagement in older patients undergoing surgery for gastrointestinal cancer: A retrospective, before-and-after study. J Am Med Dir Assoc 2022; 23:1868.e9–16

8.

Hall DE, Arya S, Schmid KK, Carlson MA, Lavedan P, Bailey TL, Purviance G, Bockman T, Lynch TG, Johanning JM: Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days. JAMA Surg 2017; 152:233–40

9.

Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F: Proactive care of older people undergoing surgery (’POPS’): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age and Ageing 2007; 36:190–6

10.

Hempenius L, Slaets JP, Asselt D van, Bock GH e, Wiggers T, Leeuwen BL van: Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly cancer patients: Report on a multicentre, randomized, controlled trial. PLoS One 2013; 8:e64834

11.

Hempenius L, Slaets JP, Asselt D van, Bock TH e, Wiggers T, Leeuwen BL van: Long term outcomes of a geriatric liaison intervention in frail elderly cancer patients. PLoS One 2016; 11:e0143364

12.

Indrakusuma R, Dunker MS, Peetoom JJ, Schreurs WH: Evaluation of preoperative geriatric assessment of elderly patients with colorectal carcinoma. A retrospective study. Eur J Surg Oncol 2015; 41:21–7

13.

Jones TS, Jones EL, Richardson V, Finley JB, Franklin JL, Gore DL, Horney CP, Kovar A, Morin TL, Robinson TN: Preliminary data demonstrate the geriatric surgery verification program reduces postoperative length of stay. J Am Geriatr Soc 2021; 69:1993–9

14.

Lester PE, Ripley D, Grandelli R, Drew LA, Keegan M, Islam S: Interdisciplinary protocol for surgery in older persons: Development and implementation. J Am Med Dir Assoc 2022; 23:555–62

15.

Marcantonio ER, Flacker JM, Wright RJ, Resnick NM: Reducing delirium after hip fracture: A randomized trial. J Am Geriatr Soc 2001; 49:516–22

16.

McDonald SR, Heflin MT, Whitson HE, Dalton TO, Lidsky ME, Liu P, Poer CM, Sloane R, Thacker JK, White HK, Yanamadala M, Lagoo-Deenadayalan SA: Association of integrated care coordination with postsurgical outcomes in high-risk older adults: The perioperative optimization of senior health (POSH) initiative. JAMA Surg 2018; 153:454–62

17.

Olsson LE, Karlsson J, Berg U, Karrholm J, Hansson E: Person-centred care compared with standardized care for patients undergoing total hip arthroplasty–a quasi-experimental study. J Orthop Surg Res 2014; 9:95

18.

Ommundsen N, Wyller TB, Nesbakken A, Bakka AO, Jordhøy MS, Skovlund E, Rostoft S: Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: A randomized controlled trial. Colorectal Dis 2018; 20:16–25

19.

Paille M, Senage T, Roussel JC, Manigold T, Piccoli M, Chapelet G, Le Tourneau T, Karakachoff M, Berrut G, Decker L e, Boureau AS: Association of preoperative geriatric assessment with length of stay after combined cardiac surgery. Annals of Thoracic Surgery 2021; 112:763–9

20.

Partridge JS, Harari D, Martin FC, Peacock JL, Bell R, Mohammed A, Dhesi JK: Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. Br J Surg 2017; 104:679–87

21.

Prestmo A, Hagen G, Sletvold O, Helbostad JL, Thingstad P, Taraldsen K, Lydersen S, Halsteinli V, Saltnes T, Lamb SE, Johnsen LG, Saltvedt I: Comprehensive geriatric care for patients with hip fractures: A prospective, randomised, controlled trial. Lancet 2015; 385:1623–33

22.

Richter HE, Redden DT, Duxbury AS, Granieri EC, Halli AD, Goode PS: Pelvic floor surgery in the older woman: Enhanced compared with usual preoperative assessment. Obstet Gynecol 2005; 105:800–7

23.

Romano LU, Rigoni M, Torri E, Nella M, Morandi M, Casetti P, Nollo G: A propensity score-matched analysis to assess the outcomes in pre-and post-fast-track hip and knee elective prosthesis patients. Journal of Clinical Medicine 2021; 10:1–13

24.

Shyu Y-IL, Liang J, Wu C-C, Su J-Y, Cheng H-S, Chou S-W, Chen M-C, Yang C-T: Interdisciplinary intervention for hip fracture in older taiwanese: Benefits last for 1 year. The Journals of Gerontology: Series A 2008; 63:92–7

25.

Shyu Y-IL, Liang J, Wu C-C, Su J-Y, Cheng H-S, Chou S-W, Yang C-T: A pilot investigation of the short-term effects of an interdisciplinary intervention program on elderly patients with hip fracture in taiwan. Journal of the American Geriatrics Society 2005; 53:811–8

26.

Smoor RM, Dongen EPA van, Daeter EJ, Emmelot-Vonk MH, Cremer OL, Vernooij LM, Noordzij PG: The association between preoperative multidisciplinary team care and patient outcome in frail patients undergoing cardiac surgery. Journal of Thoracic and Cardiovascular Surgery 2023 doi:10.1016/j.jtcvs.2023.05.037

27.

Souwer ETD, Bastiaannet E, Bruijn S e, Breugom AJ, Bos F van den, Portielje JEA, Dekker JWT: Comprehensive multidisciplinary care program for elderly colorectal cancer patients: "From prehabilitation to independence". Eur J Surg Oncol 2018; 44:1894–900

28.

Staiger RD, Curley D, Attwood NV, Haile SR, Arulampalam T, Simpson JC: Surgical outcome improvement by shared decision-making: Value of a preoperative multidisciplinary target clinic for the elderly in colorectal surgery. Langenbecks Arch Surg 2023; 408:316

29.

Tarazona-Santabalbina FJ, Llabata-Broseta J, Belenguer-Varea A, Alvarez-Martinez D, Cuesta-Peredo D, Avellana-Zaragoza JA: A daily multidisciplinary assessment of older adults undergoing elective colorectal cancer surgery is associated with reduced delirium and geriatric syndromes. J Geriatr Oncol 2019; 10:298–303

30.

Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J: Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: A randomized, controlled trial. J Am Geriatr Soc 2005; 53:1476–82

31.

Vochteloo AJ, Moerman S, Burg BL van der, Boo M e, Vries MR e, Niesten DD, Tuinebreijer WE, Nelissen RG, Pilot P: Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium. BMC Geriatr 2011; 11:39

32.

Watne LO, Torbergsen AC, Conroy S, Engedal K, Frihagen F, Hjorthaug GA, Juliebo V, Raeder J, Saltvedt I, Skovlund E, Wyller TB: The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: Randomized controlled trial (oslo orthogeriatric trial). BMC Med 2014; 12:63

33.

Zhu T, Yu J, Ma Y, Qin Y, Li N, Yang H: Effectiveness of perioperative comprehensive evaluation of hip fracture in the elderly. Comput Intell Neurosci 2022; 2022:4124354