Survey and Interview Findings of an Environmental Scan of Perioperative Geriatric Models of Care in Canada*

Mubeena Mistry, BSc(HON)1, Camilla L. Wong, MD, MHSc2,3, Sarah Wei-Ping Chan, MD4, Daniel I. McIsaac, MD, MPH5, Rachel G. Khadaroo, MD, PhD6, Bonnie Cheung, MD1

1Temerty Faculty of Medicine, University of Toronto, Toronto
2Department of Medicine, Temerty Faculty of Medicine, University of Toronto, ON
3Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON
4Faculty of Medicine, University of Ottawa, Ottawa, ON
5Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON
6Department of Surgery, University of Alberta, Edmonton, AB, Canada




Best practice recommendations support the implementation of perioperative geriatric care models that tailor to the specific needs of older adults undergoing surgery. The objective of this study was to describe the current proactive perioperative geriatric programs and pathways in Canadian hospitals.


A survey of geriatricians, surgeons, and anesthesiologists practicing in Canada combined with phone interviews of a subset of participants were used to determine characteristics of perioperative geriatric pathways or programs including eligibility, team composition, and intervention elements.


Analysis of 132 survey respondents and 24 interviews showed 47% (40 out of 85) of hospitals described had elements of a perioperative geriatrics program and 20% had two or more elements. Eleven themes emerged including: how perioperative geriatric care programs built geriatric competencies in other health-care providers; geriatric assessment identified risks not captured in standard perioperative risk assessment; perceived value for patients and the health-care team; delirium prevention was addressed; most programs were reactive; most programs were informal; virtual care may be used to meet demand; successful implementation required system buy-in with collaboration across subspecialties; mechanisms to drive improvement were accountability and data evaluation; few clinicians with geriatric expertise; and other priorities limited program implementation.


There were few hospitals in Canada with perioperative geriatric care models and even fewer with elements spanning the entire perioperative pathway. Strengths, weaknesses, opportunities, and threats to inform the implementation and sustainability of perioperative geriatric care in the Canadian context were identified in this national environmental scan.

Key words: perioperative, geriatrics, survey


The rate of aging worldwide is increasing.(1) Canada will soon become a “super-aged” society, with more than 20% of its population over the age of 65 by 2024.(2) The average patient undergoing elective and emergency surgery has become older and more likely to live with frailty over time.(3) However, older patients living with frailty experience more adverse post-operative outcomes, with odds ratios ranging from 1.5 to 4.8 compared with younger patients.(4,5) Multiple factors underlie this age-related risk. Patient-level factors include physiological changes of aging, multi-morbidity, and frailty and other geriatric syndromes.(58) System factors also contribute, as traditional reactive models of surgical care may not be tailored to deliver for older adults.(9) Very few ‘whole-pathway’ approaches to older age-friendly surgical care, that is, multicomponent and multidisciplinary intervention with integration across community and social care that starts preoperatively and continues through to proactive discharge planning with follow-up services, have been implemented.(10,11)

Comprehensive geriatric assessment (CGA) is the cornerstone of geriatric medicine that is a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological, and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up.(12) A systematic review of randomized trials comparing CGA to standard care found that older people undergoing surgery who received a CGA had a lower risk of mortality and were more likely to return to their preoperative residence (RR 0.71, 95% CI 0.55 to 0.92).(13) Perioperative geriatric care models in orthopaedics, vascular surgery, urology, trauma, general surgery, cancer surgery, and spine surgery have demonstrated improved clinical outcomes, including reductions in delirium, postoperative complications, length of stay, mortality, and discharge to higher level of care.(1419) Based on this increasing body of evidence, the American College of Surgeons has published standards for geriatric surgery which address institutional investment (securing administrative and leadership support to establish geriatric surgical care as a priority), clinical practice (shared decision making, geriatric specific assessment, interdisciplinary collaboration), and programmatic infrastructure (standardized protocols across the perioperative pathway integrated into institutional operations).(20)

The current landscape of geriatric models of perioperative care is well-described in the United Kingdom (UK) and Australasia; both regions describe an appetite for geriatric surgical care, but identify barriers including funding and workforce shortage challenges.(21,22) Conversely, there is no comprehensive data on how perioperative geriatric care is delivered in Canada. The objective of this study was to conduct a systematic national environmental scan of the presence of structured perioperative geriatric programs and pathways in hospitals across Canada. We aimed to describe current proactive perioperative geriatric programs and pathways in Canadian hospitals; eligibility criteria, components, and providers of these perioperative geriatric programs and pathways; and to provide guidance on operationalizing perioperative geriatric care in Canada. Four principles differentiate ‘proactive’ from reactive models: “1) systematic case finding, 2) early involvement, 3) focus on evidence-based strategies to prevent geriatric syndromes including delirium, falls, functional decline, incontinence, and 4) direct implementation of recommendations.”(23) To the best of our knowledge, this is first-ever data on the state of proactive perioperative geriatric models/pathways.


Study Design

This study was a cross-sectional electronic survey followed by one-on-one semi-structured phone interviews for a subset of participants to provide further qualitative data regarding existing programs and pathways. This study is reported using the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)(24) (Appendix A1).

Study Population and Recruitment

Geriatricians, anesthesiologists, and general surgeons practicing in Canada who are on the email distribution lists from the Canadian Geriatrics Society, Canadian Anesthesiologists’ Society, and/or Canadian Association of General Surgery were identified. Additional physician emails were identified through public domain directories. Two reminder emails were sent at two weeks after the initial recruitment email and then at 30 days after the first reminder.(25) The survey link was also distributed via Twitter. We used snowball recruitment whereby survey respondents were encouraged to forward the survey to colleagues. Study participants were also asked to participate in a one-on-one semi-structured phone interview for more detailed qualitative data acquisition. The option to enter a draw for a gift card was used to incentivize study participation.

Survey Development

Development of individual questionnaire items was guided by standard methods of survey research,(26) review of best practice guidelines on perioperative geriatrics from the American College of Surgeons and American Geriatrics Society,(20) as well as similar national surveys of perioperative geriatric care models conducted in the UK and Australasia.(21,22) The final survey comprised of 24 questions exploring the existence of established pathways or programs for proactive perioperative geriatric care. If such a pathway or program existed, further information was gathered regarding hospital and province of location, type of surgery, patient eligibility criteria, program elements (an element was defined as any preoperative, intraoperative or postoperative intervention option listed in questions 11, 12, 17, 21), assessment and management stratified by stage of perioperative course (preoperative, intraoperative, postoperative), and team composition. The survey used a combination of up to 20 multiple choice and four open-ended questions. The content of the survey was peer-reviewed by geriatricians and surgeons for face validity and clarity (n = 3). Feedback from testing was used iteratively to construct the final questionnaire. Test-retest reliability was conducted by administering the final questionnaire twice at two weeks apart to three participants fulfilling the inclusion criteria, consisting of one geriatrician and two surgeons. Out of all the questions, one rater had three questions with differing responses, another rater had all the same responses, and the third rater had two questions with differing responses.

Survey Administration

The final self-administered questionnaire (Appendix A2) was administered using Google Forms (Google Inc., Mountain View, CA) between September and December 2019. Information on study participation was presented prior to the questionnaire and consent was implied by completing the questionnaire.

Semi-Structured Phone Interviews

A follow-up invitation was sent to those survey respondents who indicated an interest in participating in a 15-minute phone interview. A reminder email was sent two weeks after the follow-up invitation. A series of pre-planned questions were used to conduct a semi-structured interview (Appendix A3). Phone interviews were conducted, recorded, and transcribed by one of two study authors (BC and MM). If the participant reported to be working at a hospital with a structured perioperative geriatrics pathway or program, four questions exploring the pathway or program’s benefit to patients, benefit to the health-care team, areas for improvement, and details including postoperative team composition were discussed. If the participant did not work in a hospital with a pathway or program, two questions exploring potential expected benefits of establishing a pathway or program and resources needed to create a pathway or program at their hospital were discussed. Further questions were asked throughout the interview for clarification and additional details.

Data Analysis

Multiple choice responses were reported as frequencies and proportions. In scenarios of discrepancies between respondents from the same hospital, the more inclusive response was accepted, with the recognition that one or more of the respondents from the same hospital may not have been aware of all the initiatives/protocols in place at their institution. Free text responses and verbal responses from the phone interview were transcribed and analyzed using an inductive approach to identify themes. Qualitative data were coded by key features and collated into themes using an inductive approach by two study authors (MM and CW) independently, such that themes were generated from the data rather than using a pre-existing theoretical framework, until saturation of themes was attained. Theme saturation was determined as the point at which no new themes were emerging from the interviews and agreed by both coders, setting a minimum of 17 interviews as informed by the literature.(27) Pair debriefing to check for congruence with the original data was used to minimize the influence of researcher subjectivity. Disagreements were resolved with consultation with a third study author (BC).

Themes were categorized using a SWOT (strengths, weaknesses, opportunities, threats) framework by two authors (MM and CW) independently. The SWOT framework was chosen as it helps to inform decision-making for service delivery based on internal (strengths and weaknesses) and external (opportunities and threats) factors gathered from surveys.(28) Applying the SWOT analysis traditionally used in competition and business strategy to the present study, strengths were defined as “internally-relating facets of perioperative geriatric programs/pathways lending them an advantage over other interventions,” weaknesses were defined as “internally-relating characteristics of perioperative geriatric programs/pathways which lead them to have a relative disadvantage against other alternatives,” opportunities were defined as “externally-related realities within the greater environment that can be leveraged to enable and/or promote the implementation/sustainment of perioperative geriatric programs/pathways,” and threats were defined as “externally-related realities within the greater environment which might pose as barriers to and/or hinder the implementation or sustainment of perioperative geriatrics programs/pathways”.(29) Differences in categorization of themes were resolved through discussion. The framework was used in this study to understand, analyze, and inform strategy related to perioperative geriatric models of care.


The study protocol was approved by the University of Toronto Health Sciences Research Ethics Board (Protocol #: 00038096).


Survey Results

There were 132 survey respondents, comprising 104 (79%) geriatricians, 14 (11%) general surgeons, 9 (7%) anaesthesiologists, and 5 (4%) ‘other’. The respondents were from 85 hospitals (15 hospitals with <200 beds) with representation from all provinces (Appendix A4). Eighty-one (61%) survey respondents reported working in an academic hospital and 70 (53%) reported working in a hospital with a geriatric-specific surgical program or care pathway. Forty of 85 (47%) hospitals had elements of a perioperative geriatric program, though 17 (20%) had two or more elements. Of the 40 hospitals with a perioperative geriatrics program or pathway, half were academic hospitals. Fifteen, five, and 30 programs targeted the pre-operative, intraoperative, and postoperative stages, respectively. Orthopedic surgery was the most common surgical service targeted (Table 1).

TABLE 1 Types of surgical services with geriatric surgical programs or pathways, by perioperative stage, in the 85 hospitals associated with survey participants


Of the 15 hospitals with a preoperative geriatric surgical program or pathway, age was the most commonly used eligibility criteria. All but one of the hospital programs with a preoperative geriatrics pathway included a geriatrician (93%) in the care delivery. Almost all of the preoperative geriatrics programs had delirium counselling (93%) and medication review (93%) as part of preoperative optimization, and used the comprehensive geriatric assessment (87%) to inform risk assessment. See Table 2 for other characteristics of preoperative geriatrics programs.

TABLE 2 Characteristics of pre-operative geriatrics programs/pathways among the 15 Canadian hospitals with pre-operative geriatrics programs/pathways


Five hospitals were described as having an intraoperative component to geriatric surgical care. Components of these intraoperative geriatric care pathways included peripheral nerve blocks, geriatric-specific management (e.g., dose-adjustments and/or drug choices), geriatric-specific IV fluid protocols, and sedation depth monitoring protocols in two, two, one, and one, programs, respectively.

Thirty hospitals were described as having a postoperative geriatrics care pathway or program, with age being the most common eligibility criteria. Common elements included the use of geriatric-specific order sets in 19 (63%), geriatric-surgery co-management models in 16 (54%), and geriatrics consultation in 15 (50%). See Table 3 for other characteristics of postoperative geriatrics programs.

TABLE 3 Characteristics of post-operative geriatrics programs/pathways among the 30 Canadian hospitals with post-operative geriatrics programs/pathways


There were six non-geriatrician respondents, for all of whom there was a geriatrician respondent from the same hospital. The non-free text answers provided by anesthesiologists and surgeons were captured by the themes from the corresponding geriatrician respondent from the same hospital. The themes in the non-free text answers were captured within the interviews.

Phone Interview Results

Of the 132 survey respondents, 24 agreed to the phone interview of which 22 (92%) were geriatricians and 2 (8%) were general surgeons, with representation from all provinces except Newfoundland and Labrador, and Saskatchewan (Appendix A4). The 24 interviewees worked at 24 different hospitals, 15 (63%) of which were academic hospitals. Fourteen (59%) of the interviewees reported working at a hospital that had a geriatric-specific program or care pathway for surgical patients. Saturation of themes was achieved before the last interview. Eleven themes were identified and categorized into the SWOT analysis framework as follows (see Figure 1): four strengths, two weaknesses, three opportunities and two threats.



FIGURE 1 Perioperative geriatric models of care in Canada
From: Canva (Sydney, Australia:

Strengths of perioperative geriatric care programs include building geriatric competencies in other health-care providers; geriatric assessment identifies risks that are not captured in standard perioperative risk assessment; there is perceived value for patients and the health-care team; and delirium prevention is addressed. Weaknesses identified included the reactive rather than proactive nature of programs and the lack of formal program recognition. Opportunities included the identification of elements of successful implementation (system buy-in, integration, coordination across space and time, collaboration with other specialties, and partnerships), mechanisms to drive improvement (accountability, data collection, and evaluation), and leveraging virtual care to meet demand. Threats to the implementation of perioperative geriatric programs include limited clinicians with geriatric expertise—including geriatricians, but also physicians with additional training in geriatrics and/or advanced practice nurses with specialization in geriatrics—and other priorities such as the COVID-19 pandemic response.

See Table 4 for details with supportive participant quotes. Thematic analysis of the two surgeon participants overlapped with the themes identified from the geriatrician participants’ interview data.

TABLE 4 SWOT analysis of themes from phone interviews on perioperative geriatric models of care in Canada with representative quotations (n = 24)



In a national environmental scan of perioperative geriatric services in Canada, based on quantitative and qualitative methods, we found that implementation of whole pathway approaches to perioperative care for older adults(10) remains low relative to the UK and Australasia. Similar to other jurisdictions, existing perioperative geriatric care models tend to focus on orthopedic surgery and processes are structured reactively, despite impressions that proactive care may be optimal. As evidence and guidelines support perioperative models of comprehensive geriatric care, future efforts are required to develop, implement, and evaluate proactive perioperative geriatric care in Canada.

While surveys of perioperative geriatric models have been conducted in the UK and Australasia, to our knowledge no such data exist in the Canadian context. Therefore, our data provide novel insights in Canada. While we found orthopaedics to be the most common surgical discipline to incorporate geriatric pathways, the uptake in Canada appears to be comparatively lower than other countries(10) such as in Australia, where 92% of older adults with hip fracture receive a geriatric review. Canada also lags behind the National Health Service (NHS) health-care trusts in the UK where 53% of trusts provided geriatric medicine services for older surgical patients.(21) Our data are consistent with existing Canadian data using physician billing claims that demonstrate that fewer than 10% of hip fracture patients, and fewer than 3% of older elective surgery patients, receive care from a geriatrician.(30,31) A further challenge in Canada is the widening geriatrician-supply gap; using the benchmark ratio of 1.25 specialists/10,000 population over 65, there was already a shortfall of 471.7 geriatricians in 2019.(32) Similar to the UK, most models in Canada are reactive rather than proactive,(21) which is contrary to best practice recommendations that suggest geriatric-led multidisciplinary care should be initiated before surgery.(11,20)

The themes identified in this study are similar to other qualitative studies in this space. System barriers limiting clinicians with geriatric expertise and the opportunity for collaboration are themes reflected in the present Canadian study and in Australasia.(33) A similar study from the UK also evaluated their system as being reactive and cited a lack of evidence.(34) The need for proactive approaches to perioperative geriatrics and for data collection are recognized across all aforementioned jurisdictions.(33,34)

While harnessing strengths and addressing weaknesses intrinsic to perioperative geriatrics, next steps would be to leverage opportunities to implement/sustain proactive perioperative geriatric programs/pathways in Canada, in addition to mitigating threats that may pose a barrier to overall implementation success. The SWOT analysis can be applied by looking to the British Geriatrics Society’s whole pathway approach and the American College of Surgeons’ Geriatric Surgery Verification Program Standards.(20,35) Successful proactive ‘whole pathway’ perioperative geriatrics models are already implemented elsewhere, including the NHS Proactive Care of Older People undergoing Surgery (POPS) service.(35,36) POPS involves a team of geriatricians, clinical nurse specialists, and allied health and incorporates preoperative CGA and optimization, and postoperative monitoring for early detection and treatment of complications, including delirium. As perspectives from Canada align with those from other jurisdictions, adoption of international solutions including POPS may be tweaked to fit the Canadian context, leveraging opportunities for multispecialty collaboration, data collection, and adaptations based on resource and geographic constraints. This highlights the need for system leaders, health advocates, and policymakers to recognize the added value of perioperative geriatrics, potentially paving the way for a national guideline.

Limitations of this study include the large number of geriatrician respondents in both the survey and phone interviews. Surgeons and anesthesiologists who participated in the study were more likely to be interested in perioperative geriatrics. Surgeon recruitment only focused on the general surgical specialty, though perioperative geriatric care seemed most common in orthopaedics. The study only focused on proactive, and not reactive, consultation. The study was conducted only in the English language and may have under-represented the experience of Francophone jurisdictions. The environmental scan represented only the physician perspective and did not capture health system managers or patient data. Lastly, the findings may be subject to reporting bias with likely over-representation from respondents interested in or involved in perioperative geriatric care, and the extent of the response bias is uncertain given the ambiguous sampling frame.


This study defined the current landscape of perioperative geriatrics care in Canada and identified the strengths, weaknesses, opportunities, and threats to inform the elements necessary for the implementation and sustainability of perioperative geriatric care in the Canadian context. The findings are similar to those found in other international surveys of models of perioperative geriatrics care including resource allocation gap, competing clinical priorities, role of data in driving change, importance of stakeholder engagement, need for evolving from reactive to proactive care delivery, joint development by different specialties, and the integral role of the geriatrician.(10) The adoption and spread of perioperative geriatric care models can be addressed using implementation science. Next steps include the establishment of multispecialty perioperative groups to engage policy makers and managers to develop surgical systems that embrace whole pathway care for the older person undergoing surgery, including a national guideline.(32)


The authors would like to thank Drs. Sharon Straus, Tyler Chesney, Karen D’Silva, Tricia Woo, Karen Ng, Barbara Haas, Fernando Angarita, Ian Randall, and Sarah Ward for their contributions in the pilot-testing and intra-rater reliability testing of the survey.


We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare there are none.


This research did not receive external funding.


1 World Health Organization. World report on ageing and health. Luxembourg: WHO; 2015. Available from:

2 Ibbitson J. (2020 Jan 26). Older, longer: the super-aging of Canadians has taken everyone by surprise [Opinion]. The Globe and Mail [Internet]. Available from:

3 Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003 Aug;238(2):170–77.
cross-ref  pubmed  pmc  

4 McVeigh TP, Al-Azawi D, O’Donoghue GT, Kerin MJ. Assessing the impact of an ageing population on complication rates and in-patient length of stay. Int J Surg. 2013 Nov 1;11(9):872–75.
cross-ref  pubmed  

5 Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr [Internet]. 2016 Dec;16(1):157. Available from:

6 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet [Internet]. 2012 Jul 7;380(9836):37–43. Available from:

7 Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr [Internet]. 2009 Jan 1;48(1):78–83. Available from:

8 Robinson TN, Wu DS, Pointer LF, Dunn CL, Moss M. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. J Am Coll Surg [Internet]. 2012 Jul 1; 215(1):12–17. Available from:

9 Partridge J, Sbai M, Dhesi J. Proactive care of older people undergoing surgery. Aging Clin Exp Res. 2018/01/04. 2018 Mar;30(3):253–57.
cross-ref  pubmed  pmc  

10 Thillainadesan J, Hilmer SN, Fleury AM, Naganathan V. New horizons in the perioperative care of older adults. Age Ageing. 2022 Feb;51(2):afab245.
cross-ref  pubmed  

11 Centre for Perioperative Care. Guideline for perioperative care for people living with frailty undergoing elective and emergency surgery. 2021 Sep [cited 2022 Oct 2]. Available from:

12 Rubenstein LZ, Stuck AE, Siu AL, Wieland D. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Soc [Internet]. 1991 Sep [cited 2022 Oct 2];39(9 Pt 2):8S–16S. Available from:

13 Eamer G, Taheri A, Chen SS, et al. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database of Systematic Reviews. 2018 Jan 31.
cross-ref  pubmed  pmc  

14 Partridge JSL, Harari D, Martin FC, et al. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. Br J Surg. 2017 May 1;104(6):679–87.
cross-ref  pubmed  

15 Braude P, Goodman A, Elias T, et al. 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 Jul;120(1):123–29.

16 Grigoryan K V, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014 Mar;28(3):e49–55.
cross-ref  pmc  

17 McDonald SR, Heflin MT, Whitson HE, et al. Association of integrated care coordination with postsurgical outcomes in high-risk older adults: the Perioperative Optimization of Senior Health (POSH) initiative. JAMA Surg. 2018 May 1;153(5):454–62.
cross-ref  pubmed  pmc  

18 Pernik MN, Deme PR, Nguyen ML, et al. Perioperative Optimization of Senior Health in Spine Surgery: Impact on Postoperative Delirium. J Am Geriatr Soc. 2021 May 1;69(5):1240–48.
cross-ref  pubmed  

19 Shahrokni A, Tin AL, Sarraf S, et al. Association of geriatric comanagement and 90-day postoperative mortality among patients aged 75 years and older with cancer. JAMA Netw Open. 2020 Aug 19;3(8):e209265.
cross-ref  pubmed  pmc  

20 American College of Surgeons. Optimal Resources for Geriatric Surgery: 2019 Standards [Internet]. Chicago; 2019. Available from:

21 Joughin AL, Partridge JSL, O’Halloran T, Dhesi JK. Where are we now in perioperative medicine? Results from a repeated UK survey of geriatric medicine delivered services for older people. Age Ageing. 2019 May 1;48(3):458–62.
cross-ref  pubmed  

22 Thillainadesan J, Hilmer S, Close J, Kearney L, Naganathan V. Geriatric medicine services for older surgical patients in acute hospitals: results from a binational survey. Aust J Ageing. 2019 Dec 1; 38(4):278–83.

23 Wong CL, Von Maltzahn M, McFarlan A, Huang A, Lee L, Haas B. Leading best practices: emerging cross-specialty collaborative care models. CGS J CME. 2017;7(1).

24 Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004 Sep 29;6(3):334.

25 Dillman DA, Smyth JD, Christian LM. Internet, phone, mail, and mixed-mode surveys: the tailored design method, 4th edition. Hoboken, NJ: John Wiley & Sons; 2014.

26 Burns KEA, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. Can Med Assoc J. 2008 Jul 29;179(3):245–52.

27 Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med [Internet]. 2022 Jan 1;114523:292 [cited 2022 Oct 2]. Available from:

28 Rowe F, Walker M, Rockliffe J, et al. Delivery of high quality stroke and vision care: experiences of UK services. Disabil Rehabil. 2016 Apr 9;38(8):813–17.

29 Teoli D, Sanvictores T, An J. SWOT analysis [Internet]. Treasure Island, FL: StatPearls Publishing; 2019. Available from:

30 Cho N, Boland L, McIsaac DI. The association of female sex with application of evidence-based practice recommendations for perioperative care in hip fracture surgery. Can Med Assoc J [Internet]. 2019 Feb 11;191(6):E151–E158. Available from:

31 McIsaac DI, Huang A, Wong CA, Wijeysundera DN, Bryson GL, van Walraven C. Effect of preoperative geriatric evaluation on outcomes after elective surgery: a population-based study. J Am Geriatr Soc [Internet]. 2017 Dec 1;65(12):2665–72. Available from:

32 Basu M, Cooper T, Kay K, et al. Updated Inventory and Projected Requirements for Specialist Physicians in Geriatrics. Can Geriatr J [Internet]. 2021 Sep 1;24(3):200–08 [cited 2022 Oct 2]. Available from:

33 Thillainadesan J, Jansen J, Close J, Hilmer S, Naganathan V. Geriatrician perspectives on perioperative care: a qualitative study. BMC Geriatr [Internet]. 2021 Jan 19;21(1):68. Available from:

34 Howie S, Tinker A. Are we on the same page? Exploring the role of the geriatrician in the care of the older surgical patient from the perspective of surgeons and geriatricians. Clin Med. 2018 Oct;18(5):374.

35 British Geriatrics Society. Guideline for the care of people living with frailty undergoing elective and emergency surgery that encompasses the whole perioperative pathway [Internet]. 2021 [cited 2023 Mar 13]. Available from:

36 Dhesi J. Proactive care of older people undergoing surgery (POPS service) [Internet]. 2012 [cited 2023 Mar 13]. Available from:

Correspondence to: Camilla Wong, MD, MHSc, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8,

(Return to Top)

*This work was presented in part at the 2022 Annual Scientific Meeting of the Canadian Geriatrics Society. ( Return to Text )

APPENDIX A1. Checklist for Reporting Results of Internet E-Surveys (CHERRIES)(24)


APPENDIX A2. Self-administered online survey

For this survey, the perioperative period will be divided into three distinct phases of a surgical procedure:

  1. Preoperative phase (time from decision to pursue surgery to the beginning of the surgical procedure);

  2. Intraoperative phase (time from the beginning of the surgical procedure to transfer to the post-anesthesia care unit);

  3. Postoperative phase (time from end of care in the post-anesthesia care unit to discharge from hospital).

General Questions

PRE-operative Geriatrics Pathway/Program

Preoperative phase (time from decision to pursue surgery to the beginning of the surgical procedure)

PRE-operative Geriatrics Pathway/Program Questions

Preoperative phase: time from decision to pursue surgery to the beginning of the surgical procedure

INTRA-operative Geriatrics Pathway/Program

Intraoperative phase: time from the beginning of the surgical procedure to the transfer to the post-anesthesia care unit

INTRA-operative Geriatrics Pathway/Program Questions

Intraoperative phase: time from the beginning of the surgical procedure to the transfer to the post-anesthesia care unit

POST-operative Geriatrics Pathway/Program

Postoperative phase: time from end of care in the post-anesthesia care unit to discharge from hospital

POST-operative Geriatrics Pathway/Program Questions

Postoperative phase: time from end of care in the post-anesthesia care unit to discharge from hospital

Final Questions

Submit Form page

Thank you for filling out this survey. If you would like to enter for a chance to win a gift card, please provide your contact information at the following link. (Link here)

APPENDIX A3. Semi-structured phone interview questions

Hello, this is [interviewer’s name here], one of the research investigators involved in the study, “A Canadian Environmental Scan of Perioperative Geriatric Models of Care”. Since you have opted to participate in a phone interview at the end of the survey and have signed the consent form, we are calling you to conduct the interview at this time.

We would like to remind you that all of the questions are completely optional to answer and you may choose to skip questions, end the interview and/or withdraw from the study at any time. Please let me know if you have any questions or concerns before we begin.

If the participant has consented to the phone interview being recorded: Please note that this interview is being recorded for transcribing purposes only.

Q1) Do you work at a hospital with a structured perioperative geriatrics program or pathway?

If participant answers “yes” to Q1:

If participant answers “no” to Q1:

Q7) What are the resources needed to create a structured perioperative geriatrics program or pathway at your hospital?

APPENDIX A4. Demographic and hospital data from survey and interviewees of perioperative geriatrics programs in Canadian hospitals



This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (, which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.

Canadian Geriatrics Journal, Vol. 26, No. 3, September 2023