Association of Routine Preoperative Frailty Assessment With 1-Year Postoperative Mortality

The Surgical Pause: The Importance of Measuring Frailty and Taking Action to Address Identified Frailty

CONCEPTUAL FRAMEWORK

The Surgical Pause is a rapid, scalable strategy for health care systems to optimize perioperative outcomes for high-risk, frail patients considering elective surgery. The first and most important step is to screen for frailty, thereby identifying the 5% to 10% of patients at most risk for postoperative complications, loss of independence, institutionalization, and mortality. The second step is to take action to improve outcomes. Action may include clarifying perioperative goals, optimizing perioperative decision-making, and mitigating frailty-associated risks through prehabilitation.

HISTORY OF DISSEMINATION

Initially implemented at the Omaha Veterans Affairs (VA) Medical Center in 2012, the Surgical Pause was associated with a nearly three-fold survival advantage among the frail. The program was subsequently replicated at more than 50 VA and private sector hospitals with similarly robust results, leading the Veterans Health Administration (VHA) National Surgery Office to formally adopt the program in January 2024. The Joint Commission and the National Quality Forum recognized the program with the Eisenberg Award for Patient Safety and Quality at the National Level.

LESSONS LEARNED

Successful dissemination grew from simultaneous real-world quality projects paralleled by rigorous, high-quality, peer reviewed publications demonstrating the need for and impact of the Surgical Pause. Adoption was facilitated in an iterative process to streamline feasibility and leverage existing resources. Success was accelerated by national infrastructure catalyzing a community of practice.

CONCLUSION

The Surgical Pause is changing surgical culture by proactively identifying frail patients, aligning treatment plans with patient-defined goals, optimizing perioperative decisions, and mitigating frailty-associated risks to deliver both quality and value.

Prevalence and factors influencing preoperative frailty in elderly patients with gynecologic oncology surgery: A cross-sectional study

BACKGROUND

Frailty is an important predictor of poor postoperative outcomes in elderly patients with gynaecologic cancer. However, the prevalence and risk factors for frailty in this population remain unclear.

METHODS

This cross-sectional study was conducted simultaneously in three gynecology departments of a tertiary hospital in China between January and March 2024. The study recruited 126 hospitalised patients with gynaecologic malignancies who underwent surgery. The demographic and clinical characteristics and biochemical laboratory parameters of all patients were collected. The Edmonton Frailty Scale was used to assess the patient's frailty. Multivariate logistic regression model analysis was used to identify the influencing factors of frailty.

RESULTS

The prevalence of preoperative frailty was 31 %. Univariate analysis showed significant differences between frail and non-frail groups in terms of age, body mass index, menopausal status, self-management ability, nutritional risk and activities of daily living (ADL) (all p < 0.05). Multiple logistic regression analysis identified older age (odds ratio [OR] = 1.27, 95%CI: 1.068-1.511, p = 0.007), ADL disability (OR = 3.184, 95%CI: 2.294-4.833, p = 0.010) and high nutritional risk (Nutritional Risk Screening 2002 score ≥ 3) (OR = 4.823, 95%CI: 1.422-16.816, p = 0.031) as risk factors for frailty. High self-management ability (OR = 0.918, 95%CI: 0.844-0.998, p = 0.046) was a protective factor against frailty.

CONCLUSION

Nutritional support, activity exercise and improvement of patient self-management are potential intervention goals, and nurses should develop targeted prevention strategies based on identified risk factors to protect patient health.

Frailty Screening Using the Risk Analysis Index: A User Guide

The Risk Analysis Index (RAI) has emerged as the most thoroughly validated and flexible assessment of surgical frailty, proven feasible for at-scale bedside screening and available in a suite of tools, that effectively risk stratifies patients across a wide variety of clinical contexts and data sources. This user guide provides a definitive summary of the RAI's theoretical model, historical development, validation, statistical performance, and clinical interpretation, placing the RAI in context with other frailty assessments and emphasizing some of its advantages. Detailed instructions are provided for each RAI variant, along with a systematic review of existing RAI-related literature.

Frailty and Long-Term Health Care Utilization After Elective General and Vascular Surgery

Importance

Surgical quality improvement efforts have largely focused on 30-day outcomes, such as readmissions and complications. Surgery may have a sustained impact on the health and quality of life of patients considered frail, yet data are lacking on the long-term health care utilization of patients with frailty following surgery.

Objective

To examine the independent association of preoperative frailty on long-term health care utilization (up to 24 months) following surgery.

Design, Setting, and Participants

This retrospective, observational cohort study included patients undergoing elective general and vascular surgery performed in the Veterans Affairs (VA) Surgical Quality Improvement Program with study entry from October 1, 2013, to September 30, 2018. Patients were followed up for 24 months. Patients with nursing home visits prior to surgery, emergent cases, and in-hospital deaths were excluded. Data analysis was conducted from September 2022 to May 2024.

Exposures

Preoperative frailty as assessed by the Risk Analysis Index (RAI-A) score: robust, less than 20; normal, 20 to 29; frail, 30 to 39; and very frail, 40 or more.

Main Outcomes and Measures

The primary outcome was health care utilization through 24 months, defined as inpatient admissions, outpatient visits, emergency department (ED) visits, and nursing home or rehabilitation services collected via Corporate Data Warehouse and Centers for Medicare & Medicaid Services data. χ2 Tests and analysis of variance were used to assess preoperative frailty status, and a Cox proportional hazards model was used to calculate the adjusted association of preoperative frailty on each postdischarge health care utilization outcome.

Results

This study identified 183 343 elective general (80.5%) and vascular (19.5%) procedures (mean [SD] age, 62 [12.7] years; 12 915 females [7.0%]; 28 671 Black patients [16.0]; 138 323 White patients [77.3%]; 94 451 Medicare enrollees [51.5%]) with mean (SD) RAI-A score of 22.2 (7.0). After adjustment for baseline characteristics and preoperative use of health care services, frailty was associated with higher inpatient admissions (frail: hazard ratio [HR], 1.75; 95% CI, 1.70-1.79; very frail: HR, 2.33; 95% CI, 2.25-2.42), ED visits (frail: HR, 1.39; 95% CI, 1.36-1.41; very frail: HR, 1.70; 95% CI, 1.65-1.75), and nursing home or rehabilitation encounters (frail: HR, 4.97; 95% CI, 4.36-5.67; very frail: HR, 7.44; 95% CI, 6.34-8.73). For patients considered frail and very frail, health care utilization was higher after surgery and remained significant through 24 months for all outcomes (using piecewise Cox proportional hazards modeling).

Conclusions and Relevance

In this study, frailty was a significant risk factor for high long-term health care utilization after surgery. This may have quality of life implications for patients and policy implications for health care systems and payers.

Association Between Frailty and Preoperative Decision-Making in Rectal Prolapse Repair

INTRODUCTION

Abdominal and perineal repairs for rectal prolapse are offered to patients based on surgeon assessment of risk. Interpretations of risk can vary. We sought to understand how the preoperative Risk Analysis Index (RAI) score, a validated measure of frailty, aligned with our existing decision-making process for rectal prolapse repair.

METHODS

Rectal prolapse repair cases were recorded in an Institutional Review Board approved registry from 2017 to 2022. Abdominal and perineal operations were determined based on an experienced surgeon's recommendation. The preoperative RAI was collected; a score≥30 indicates significant frailty. Preoperative and postoperative characteristics were compared using t-tests and Fisher's exact tests.

RESULTS

About 130 patients underwent abdominal repairs and 51 underwent perineal repairs. Perineal patients were more often frail (abdominal: 9 [7%] versus perineal: 21 [41%], P < 0.001) and had a higher rate of cardiac comorbidities (abdominal: 42 [32%] versus perineal: 35 [69%], P < 0.001). A similar share of patients were undergoing repair for recurrent prolapse (abdominal: n = 29 [22%] versus perineal: n = 11 [22%], P > 0.99). Perineal repair patients were more likely to need assistance with mobility (n = 24 [47%]) and live in a facility (n = 15 [29%]). Patients in both groups recovered well (complication rate abdominal: 28 [22%] versus 11 [22%], P > 0.99) and were satisfied with postoperative outcomes (Patient Global Impression of Change score abdominal: 6 [interquartile range: 6, 7] versus perineal: 6 [5, 7], P = 0.12). Recurrence rates were higher after perineal repair (abdominal: 12 [9%] versus perineal: 20 [39%], P < 0.001).

CONCLUSIONS

Most abdominal repair patients were not frail, but many nonfrail patients underwent perineal operations based on surgeon perception of comorbidities. Using the RAI tool may provide an opportunity to guide decision-making around operative approach for rectal prolapse and overcome potential surgeon bias.

The pervasive impact of frailty on ovarian cancer care and the role of prehabilitation: Qualitative perspectives of key stakeholders

INTRODUCTION

We performed a qualitative study to explore key stakeholders' perspectives about the impact of frailty on ovarian cancer care and evaluate a candidate prehabilitation intervention.

MATERIALS AND METHODS

We conducted semi-structured interviews with patient-caregiver dyads and multi-disciplinary clinicians. Patients were ≥ 50 years of age with a new diagnosis of advanced stage (III/IV) ovarian cancer who received cancer-directed treatment (chemotherapy and/or surgery) during the past year and met criteria as pre-frail or frail using the FRAIL scale. We used a semi-structured interview guide to elicit participants' views on frailty, nutrition, physical therapy, and a candidate prehabilitation intervention. We used inductive and deductive approaches to code and analyze interviews and identify emergent themes and patterns.

RESULTS

Ten patients and caregivers (five dyads) and 10 providers were interviewed. We identified four themes: (1) frailty screening is essential to prevent over- and under-treatment, but underused; (2) stakeholders preferred a multidisciplinary approach to providing tailored care for frail patients over a candidate prehabilitation intervention; (3) patient, family caregiver, and clinician stakeholders reported multiple barriers to prehabilitation programs, including concerns about selection bias, and (4) frail patients and family members are vulnerable and require more psychosocial support.

DISCUSSION

We identified significant barriers to prehabilitation interventions for frail patients with ovarian cancer; initiatives to increase frailty screening and provide tailored multi-disciplinary approaches may have a greater impact.

Screening for Percutaneous Lung Cryoablation Adverse Event Risk: A Single-Center Comparative Analysis to Surgical Risk Estimates

OBJECTIVE

To evaluate the relevance of established surgical risk calculators for predicting complications in patients undergoing percutaneous lung cryoablation (PLC).

METHODS

The institution's database was queried for PLC procedures from March 2015 to May 2024, excluding those patients with concomitant local therapies or five or more lesions treated in a single setting. Demographics, frailty metrics as defined by the surgical literature, and procedural variables were collected. To evaluate the suitability of surgical risk estimate calculators, the requisite demographic data were input into the American College of Surgery surgical risk calculator; estimates for length of stay (LOS), serious complications, 30-day readmission, and mortality were calculated to determine the comparative risk profile were the patients to have undergone surgical wedge resection instead of PLC. Additionally, to evaluate the suitability of imaging predictors of complications, the volume of emphysematous lung was calculated using a machine learning algorithm and incorporated into a generalized estimating equation logistic regression analysis of other demographic and technical variables.

RESULTS

The study included 217 patients who underwent 314 procedures. Chest tubes were placed in 49% of procedures. The median LOS was 1 day (interquartile range: 1-1, range: 0-13). The median percentage of emphysema within the lungs was 5.9% (interquartile range: 2.4%-12.1%, range: 0.01%-50.3%). The median predicted surgical rates for serious complications (13.5%), 30-day readmission (12%), and 30-day mortality (5.9%) were all greater than actual rates after PLC (1.6%, 4.8%, and 0.3%, respectively). The estimated surgical LOS differed significantly from the actual PLC LOS (5 days versus 1 day, P < .001). In univariable analysis, the number of probes the number of tumors ablated (odds ratio 1.90, 95% confidence interval 1.18-3.05, P = .008) and the number of probes used (odds ratio 1.44, 95% confidence interval 1.06-1.96, P = .021) were significantly associated with increased LOS, but demographic and emphysema details were not.

CONCLUSION

Complications after PLC are significantly less frequent than the estimated complication risks for wedge resection in the same patient population. Risk estimate calculators tailored to PLC would help screen for high complication risks related to this procedure.

Assessment of Racial Bias within the Risk Analysis Index of Frailty

Objective

Our objective was to assess potential racial bias within the Risk Analysis Index (RAI).

Background

Patient risk measures are rarely tested for racial bias. Measures of frailty, like the RAI, need to be evaluated for poor predictive performance among Black patients.

Methods

Retrospective cohort study using April 2010-March 2019 Veterans Affairs Surgical Quality Improvement Program and 2010-2019 National Surgical Quality Improvement Program data. The performance of the RAI and several potential variants were compared between Black and White cases using various metrics to predict mortality (180-day for Veterans Affairs Surgical Quality Improvement Program, 30-day for National Surgical Quality Improvement Program).

Results

Using the current, clinical threshold, the RAI performed as good or better among Black cases across various performance metrics versus White. When a higher threshold was used, Black cases had higher true positive rates but lower true negative rates, yielding 2.0% higher balanced accuracy. No RAI variant noticeably eliminated bias, improved parity across both true positives and true negatives, or improved overall model performance.

Conclusions

The RAI tends to predict mortality among Black patients better than it predicts mortality among White patients. As existing bias-reducing techniques were not effective, further research into bias-reducing techniques is needed, especially for clinical risk predictions. We recommend using the RAI for both statistical analysis of surgical cohorts and quality improvement programs, such as the Surgical Pause.

Implementation of a preoperative frailty screening and optimization pathway for vascular surgery patients is associated with decreased 30-day readmission

OBJECTIVE

Frailty is characterized by decreased physiological reserve and vulnerability to adverse events in the presence of a stressor such as surgery. We prospectively implemented a preoperative frailty screening and optimization pathway for patients undergoing vascular surgery and assessed its impact on postoperative outcomes.

METHODS

As part of an ongoing quality improvement initiative, surgical frailty was assessed prospectively in all patients undergoing inpatient surgery using the Risk Analysis Index (RAI). Baseline data were collected from May to July 2022. Frail patients (RAI score of ≥37) were referred to an anesthesia optimization clinic, nutrition consultation, and case management evaluation in the intervention phase (August 2022 to July 2023). Primary outcomes were postoperative hospital length of stay, 30-day readmission, and 30-day mortality. Secondary outcomes included intensive care unit (ICU) admission, ICU length of stay, discharge disposition, and nonhome discharge. Two-way analyses compared frail vs nonfrail patients and preintervention vs postintervention groups using the Student t test or Wilcoxon rank-sum test for continuous variables and the χ2 or Fisher's exact test for categorical outcomes.

RESULTS

Of all patients scheduled for elective inpatient vascular surgery procedures at a single institution (n = 225), 216 completed frailty screening (mean age, 72 years; 68.5% male; 54.6% White; mean RAI, 28.9; 18.5% frail). Of these, 15 had surgeries cancelled, and 201 ultimately underwent surgery with 36 (17.9%) identified as frail. Overall, frail patients had significantly longer ICU (median, 4.0 days [intertquartile range (IQR), 2.5-13.5 days] vs median, 2.0 days [IQR, 1-4 days]; P = .001) and hospital length of stay (median, 2.45 days [IQR, 1.51-5.67 days] vs median, 1.23 days [IQR, 1.0-2.1 days]; P = .001), higher nonhome discharge (30.6% vs 4.2%; P < .0001), and higher 30-day readmission (22.2% vs 6.7%; P = .009) compared with nonfrail patients. Comparing preintervention and postintervention groups, the 30-day readmission rates for the overall cohort decreased significantly (from 22.2% to 7.5%; P = .03). Among frail patients, there was a trend toward a reduced hospital length of stay (from 4.73 to 2.14 days), nonhome discharge (from 57.1% to 24.1%), and 30-day readmission (from 42.9% to 17.2%); however, these differences did not reach statistical significance. Overall, the 30-day mortality rate was 1.5% with all three deaths (two frail, one nonfrail) occurring during the postintervention period (0% pre vs 1.7% post; P = 1.0).

CONCLUSIONS

Successful implementation of a preoperative frailty screening and optimization pathway for patients undergoing elective vascular surgery led to a significant decrease in overall 30-day readmission and a trend toward reduced hospital length of stay, nonhome discharge, and 30-day readmission for frail patients. Further expansion to all surgical clinics has the potential to improve quality metrics for the health care system.

Surgical Oncology Care for Patients With Frailty-Is the Juice Worth the Squeeze?

This Viewpoint describes how frailty assessments should be incorporated into surgical oncology decision-making for older adults with head and neck cancer.

Association of preoperative cognitive frailty with postoperative complications in older patients under general anesthesia: a prospective cohort study

BACKGROUND

Cognitive frailty (CF) is characterized by the coexistence of physical frailty and cognitive impairment, and it is associated with adverse health outcomes. Older adults are particularly vulnerable to CF due to factors such as age-related brain changes and the presence of comorbidities.

OBJECTIVE

To investigate the effect of preoperative CF on postoperative complications in older patients.

METHODS

This prospective cohort study was conducted among 253 patients aged 60-85 years, who underwent elective orthopedic and abdominal surgery (with a postoperative hospital stay of ≥ 3 days) at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2023 to November 2023. CF was assessed using the Montreal Cognitive Assessment (MoCA) for the cognitive status and the Fried criteria for five frailty scales. Participants were split into four groups: Group A (neither frailty nor cognitive impairment), Group B (frailty without cognitive impairment), Group C (cognitive impairment without frailty), and Group D (cognitive frailty). The primary outcome was postoperative complications, while secondary outcomes included mobility disability, prolonged hospital stay (PLOS), re-operation and 90-day readmission.

RESULTS

The median age (interquartile range) of participants was 69 (65-73) years, of which 40.3% were male. The prevalence of CF was 17.8%. The incidence of postoperative complications was 18.2% in Group A, 50.0% in Group B, 37.4% in Group C, and 75.6% in Group D. Multivariate analysis revealed that, compared to the control group (without cognitive impairment or frailty), patients with CF had a significantly higher risk of postoperative complications (OR, 12.86; 95%CI, 4.23-39.08). "Patients with frailty without cognitive impairment" had an increased risk (OR, 6.53; 95%CI, 2.04-20.9), while "those with cognitive impairment without frailty" also showed a higher risk (OR, 3.46; 95%CI, 1.57-7.64).

CONCLUSIONS

Cognitive frailty is significantly associated with an increased risk of postoperative adverse outcomes in older patients undergoing orthopedic and abdominal surgeries with general anesthesia. It indicates that clinicians should pay much attention to these older adults with CF.

Preinjury Frailty Predicts 1-Year Mortality in Older Adults With Traumatic Spine Fractures

BACKGROUND AND OBJECTIVES

Nearly 30% of older adults presenting with isolated spine fractures will die within 1 year. Attempts to ameliorate this alarming statistic are hindered by our inability to identify relevant risk factors. The primary objective of this study was to develop a prediction model that identifies feasible targets to limit 1-year mortality.

METHODS

This retrospective cohort study included 703 older adults (65 years or older) admitted to a level I trauma center with isolated spine fractures, without neural deficit, from January 2013 to January 2018. Multivariable analysis was used to select for independently significant patient demographics, frailty variables, injury metrics, and management decisions to incorporate into distinct logistic regression models predicting 1-year mortality. Variables were considered significant, if P < .05.

RESULTS

Of the 703 older adults, 199 (28.3%) died after hospital discharge, but within 1 year of index trauma. Risk Analysis Index (RAI; odds ratio [OR]: 1.116; 95% CI: 1.087-1.149; P < .001) and ambulation requiring a cane (OR: 2.601; 95% CI: 1.151-5.799; P = .02) or walker (OR: 4.942; 95% CI: 2.698-9.196; P < .001), ie, frailty variables, were associated with increased odds of 1-year mortality. Spine trauma scales were not associated with 1-year mortality. Longer hospital stays (OR: 1.112; 95% CI: 1.034-1.196; P = .004) and nursing home discharge (OR: 3.881; 95% CI: 2.070-7.378; P < .001) were associated with increased odds, while discharge to rehab (OR: 0.361; 95% CI: 0.155-0.799; P = .014) decreased 1-year mortality odds. A "preinjury" regression model incorporating Risk Analysis Index and ambulation status resulted in an area under receiver operating characteristic curve (AUROCC) of 0.914 (95% CI: 0.863-0.965). A "postinjury" model incorporating Glasgow Coma Scale, hospital stay duration, and discharge disposition resulted in AUROCC of 0.746 (95% CI: 0.642-0.849). Combining elements of the preinjury and postinjury models into an "integrated model" produced an AUROCC of 0.908 (95% CI: 0.852-0.965).

CONCLUSION

Preinjury frailty measures are most strongly associated with 1-year mortality outcomes in older adults with isolated spine fractures. Incorporating injury metrics or management decisions did not enhance predictive accuracy. Further work is needed to understand how targeting frailty may reduce mortality.

Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries

BACKGROUND

Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress.

METHODS

This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure.

RESULTS

In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category.

CONCLUSIONS

These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.

Association between preoperative phase angle and all-cause mortality after cardiovascular surgery: A retrospective cohort study

BACKGROUND

The importance of preoperative physical function assessment for post-operative intervention has been reported in older patients undergoing cardiovascular surgery. Phase angle (PhA), measured using bioelectrical impedance analysis, is an indicator of cellular health and integrity and is reported as a prognostic factor in several chronic diseases; however, its association with the long-term prognosis of cardiovascular surgery remains unclear. This study aimed to investigate the prognostic value of PhA for long-term mortality in patients undergoing cardiovascular surgery.

METHODS

This retrospective cohort study included consecutive patients who underwent elective cardiovascular surgery between October 2016 and March 2021 at Nagoya Heart Center, Japan. PhA was assessed using bioelectrical impedance analysis before surgery, and physical function measures (gait speed, grip strength and short physical performance battery [SPPB]) were measured synchronously. The association between PhA and all-cause mortality after discharge was assessed using Kaplan-Meier and multivariate Cox regression analyses. The incremental prognostic value of PhA was compared with other physical function measures using net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

RESULTS

A total of 858 patients were included in the present analysis (mean age = 68.4 ± 11.9 years, 67.6% male). PhA positively correlated with body mass index (ρ = 0.38, P < 0.001), skeletal muscle mass index (ρ = 0.58, P < 0.001), usual gait speed (ρ = 0.44, P < 0.001), grip strength (ρ = 0.73, P < 0.001) and SPPB (ρ = 0.51, P < 0.001). The mean follow-up period, within which 44 (4.7%) died, was 908.9 ± 499.9 days for the entire cohort. Kaplan-Meier survival curves based on the PhA tertiles showed that higher PhA was associated with better survival (log-rank test, P < 0.001). The Cox regression analysis showed the independent association of PhA with mortality risk (hazard ratio: 0.91 per 0.1° increment; 95% confidence interval [CI]: 0.87-0.95; P < 0.001). The NRI and IDI showed significant improvements in predicting mortality after adding PhA to the clinical model consisting of age, sex and cardiac and renal function (NRI: 0.426, 95% CI: 0.124-0.729, P = 0.006; IDI: 0.037, 95% CI: 0.012-0.062, P = 0.003). The predictive model consisting of the clinical model and PhA was superior to the model consisting of the clinical model and each of the other physical function indicators (P < 0.05).

CONCLUSIONS

PhA correlated with physical function and independently predicted long-term mortality after cardiovascular surgery. The additive prognostic value of PhA compared with the other physical function measures suggests the clinical usefulness of preoperative PhA for risk stratification in planning post-operative treatment and rehabilitation.

The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair

OBJECTIVE

Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs).

METHODS

Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation.

RESULTS

We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients.

CONCLUSIONS

Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Increasing perioperative age and comorbidity: a 16-year cohort study at two University hospital sites in Sweden

BACKGROUND

Increasing life expectancy affects all aspects of healthcare. During surgery, elderly patients are prone to complications and have a higher risk of death. The authors aimed to investigate if adult patients undergoing surgery at a large Swedish university hospital were getting older and sicker over time and if this potential shift in age and illness severity was associated with higher patient mortality rates.

MATERIALS AND METHODS

This was a 16-year cohort study on all surgical procedures performed in adult patients 2006-2021 at two sites of Karolinska University Hospital. Study data was obtained from the surgical system, electronic medical records, and cause-of-death register. Information on age, sex, American Society of Anesthesiologists (ASA) classification, date, type, acuity and duration of surgery was collected. ICD codes were used to calculate the Charlson comorbidity index (CCI). Short-term, medium-term and long-term mortality rates were assessed. Logistic regression models were used to evaluate changes over time.

RESULTS

There were 622 814 surgical procedures 2006-2021. Age, ASA classification, and CCI increased over time ( P <0.0001). The proportions of age older than or equal to 60 years increased from 41.8 to 52.8% and of ASA class greater than or equal to 3 from 22.5 to 47.6%. Comparing 2018-2021 with 2006-2009, odds ratios (95% CIs) of 30-day, 90-day and 365-day mortality, adjusted for age, sex, non-elective surgery and ASA classification, decreased significantly to 0.75 (0.71-0.79), 0.72 (0.69-0.76), and 0.76 (0.74-0.79), respectively.

CONCLUSION

Although the surgical population got older and sicker during the 16-year study period, short-term, medium-term and long-term mortality rates decreased significantly. These demographic shifts must be taken into account when planning for future healthcare needs to preserve patient safety.

Decision making in the frail vascular surgery patient: A scoping review

Increasing evidence highlights the adverse impact of frailty and reduced physiologic reserve on surgical outcomes. Therefore, identification of frailty is essential for older adults being evaluated for vascular surgery procedures. Numerous frailty assessment tools are available to quantify the level of frailty and assist in preoperative decision making for these older patients. This review evaluates traditional and novel frailty metrics for their scientific validation, limitations, and clinical utility in vascular surgery decision-making.

Adaptation of the Risk Analysis Index for Frailty Assessment Using Diagnostic Codes

Importance

Frailty is associated with adverse outcomes after even minor physiologic stressors. The validated Risk Analysis Index (RAI) quantifies frailty; however, existing methods limit application to in-person interview (clinical RAI) and quality improvement datasets (administrative RAI).

Objective

To expand the utility of the RAI utility to available International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) administrative data, using the National Inpatient Sample (NIS).

Design, Setting, and Participants

RAI parameters were systematically adapted to ICD-10-CM codes (RAI-ICD) and were derived (NIS 2019) and validated (NIS 2020). The primary analysis included survey-weighed discharge data among adults undergoing major surgical procedures. Additional external validation occurred by including all operative and nonoperative hospitalizations in the NIS (2020) and in a multihospital health care system (UPMC, 2021-2022). Data analysis was conducted from January to May 2023.

Exposures

RAI parameters and in-hospital mortality.

Main Outcomes and Measures

The association of RAI parameters with in-hospital mortality was calculated and weighted using logistic regression, generating an integerized RAI-ICD score. After initial validation, thresholds defining categories of frailty were selected by a full complement of test statistics. Rates of elective admission, length of stay, hospital charges, and in-hospital mortality were compared across frailty categories. C statistics estimated model discrimination.

Results

RAI-ICD parameters were weighted in the 9 548 206 patients who were hospitalized (mean [SE] age, 55.4 (0.1) years; 3 742 330 male [weighted percentage, 39.2%] and 5 804 431 female [weighted percentage, 60.8%]), modeling in-hospital mortality (2.1%; 95% CI, 2.1%-2.2%) with excellent derivation discrimination (C statistic, 0.810; 95% CI, 0.808-0.813). The 11 RAI-ICD parameters were adapted to 323 ICD-10-CM codes. The operative validation population of 8 113 950 patients (mean [SE] age, 54.4 (0.1) years; 3 148 273 male [weighted percentage, 38.8%] and 4 965 737 female [weighted percentage, 61.2%]; in-hospital mortality, 2.5% [95% CI, 2.4%-2.5%]) mirrored the derivation population. In validation, the weighted and integerized RAI-ICD yielded good to excellent discrimination in the NIS operative sample (C statistic, 0.784; 95% CI, 0.782-0.786), NIS operative and nonoperative sample (C statistic, 0.778; 95% CI, 0.777-0.779), and the UPMC operative and nonoperative sample (C statistic, 0.860; 95% CI, 0.857-0.862). Thresholds defining robust (RAI-ICD <27), normal (RAI-ICD, 27-35), frail (RAI-ICD, 36-45), and very frail (RAI-ICD >45) strata of frailty maximized precision (F1 = 0.33) and sensitivity and specificity (Matthews correlation coefficient = 0.26). Adverse outcomes increased with increasing frailty.

Conclusion and Relevance

In this cohort study of hospitalized adults, the RAI-ICD was rigorously adapted, derived, and validated. These findings suggest that the RAI-ICD can extend the quantification of frailty to inpatient adult ICD-10-CM-coded patient care datasets.

Exploring the Median Effective Dose of Ciprofol for Anesthesia Induction in Elderly Patients: Impact of Frailty on ED50

Purpose

Explore the median effective dose of ciprofol for inducing loss of consciousness in elderly patients and investigate how frailty influences the ED50 of ciprofol in elderly patients.

Patients and Methods

A total of 26 non-frail patients and 28 frail patients aged 65-78 years, with BMI ranging from 15 to 28 kg/m2, and classified as ASA grade II or III were selected. Patients were divided into two groups according to frailty: non-frail patients (CFS<4), frail patients (CFS≥4). With an initial dose of 0.3 mg/kg for elderly non-frail patients and 0.25 mg/kg for elderly frail patients, using the up-and-down Dixon method, and the next patient's dose was dependent on the previous patient's response. Demographic information, heart rate (HR), oxygen saturation (SpO2), mean blood pressure (MBP), and bispectral index (BIS) were recorded every 30 seconds, starting from the initiation of drug administration and continuing up to 3 minutes post-administration. Additionally, the total ciprofol dosage during induction, occurrences of hypotension, bradycardia, respiratory depression, and injection pain were recorded.

Results

The calculated ED50 (95% confidence interval [CI]) and ED95 (95% CI) values for ciprofol-induced loss of consciousness were as follows: 0.267 mg/kg (95% CI 0.250-0.284) and 0.301 mg/kg (95% CI 0.284-0.397) for elderly non-frail patients; and 0.263 mg/kg (95% CI 0.244-0.281) and 0.302 mg/kg (95% CI 0.283-0.412) for elderly frail patients. Importantly, no patients reported intravenous injection pain, required treatment for hypotension, or experienced significant bradycardia.

Conclusion

Frailty among elderly patients does not exert a notable impact on the median effective dose of ciprofol for anesthesia induction. Our findings suggest that anesthesiologists may forego the necessity of dosage adjustments when administering ciprofol for anesthesia induction in elderly frail patients.

Minimally invasive pancreaticoduodenectomy: A favorable approach for frail patients with pancreatic cancer

BACKGROUND

Within the past decade, minimally invasive pancreaticoduodenectomy has been increasingly adopted in high-volume cancer centers. Amid broader trends of a growing older population, the numbers of frail patients with cancer are expected to increase. In this study, we compared the postoperative outcomes of open pancreaticoduodenectomy and minimally invasive pancreaticoduodenectomy in frail patients with pancreatic ductal adenocarcinoma.

METHODS

Using the pancreatectomy-targeted American College of Surgeons-National Surgical Quality Improvement Program database (2014-2021), we identified pancreaticoduodenectomy cases for pancreatic ductal adenocarcinoma. Patients with a modified frailty index ≥2 were considered frail. We performed 2:1 (open pancreaticoduodenectomy to minimally invasive pancreaticoduodenectomy) optimal pair propensity score matching for both patient- and disease-specific characteristics. We evaluated baseline covariate balance for homogeneity and assessed 30-day postoperative outcomes: complications, discharge destination, major morbidity, and mortality.

RESULTS

We identified 3,143 frail patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Of those, 275 (9%) underwent minimally invasive pancreaticoduodenectomy. Minimally invasive pancreaticoduodenectomy was associated with a lower rate of any complications compared with open pancreaticoduodenectomy (43% vs 54%; P < .001), major morbidity (29% vs 35%; P = .042), and nonhome discharge (12% vs 17%; P = .022). When comparing the 2 minimally invasive pancreaticoduodenectomy approaches, robotic surgery was associated with fewer complications compared with laparoscopy (39% vs 51%; P = .040) and a lower mortality rate (1% vs 4%; P = .041) CONCLUSION: In frail patients with pancreatic cancer, minimally invasive pancreaticoduodenectomy was associated with better postoperative outcomes than open pancreaticoduodenectomy. This study builds on growing literature reporting that, when properly implemented, minimally invasive pancreaticoduodenectomy is associated with more favorable postoperative outcomes. Given the particularly high risk of complication in frail patients, implementing a preoperative frailty assessment can provide valuable insights to inform patient counseling.

Preoperative Frailty and Malnutrition in Surgical Oncology Patients Predicts Higher Postoperative Adverse Events and Worse Survival: Results of a Blinded, Prospective Trial

BACKGROUND

Frailty, a multidimensional state leading to reduced physiologic reserve, is associated with worse postoperative outcomes. Despite the availability of various frailty tools, surgeons often make subjective assessments of patients' ability to tolerate surgery. The Risk Analysis Index (RAI) is a validated preoperative frailty assessment tool that has not been studied in cancer patients with plans for curative-intent surgery.

METHODS

In this prospective, surgeon-blinded study, patients who had abdominal malignancy with plans for resection underwent preoperative frailty assessment with the RAI and nutrition assessment by measurement of albumin, prealbumin, and C-reactive protein (CRP). Postoperative outcomes and survival were assessed.

RESULTS

The study included 220 patients, 158 (72%) of whom were considered frail (RAI ≥21). Frail patients were more likely to be readmitted within 30 and 90 days, (16% vs. 3% [P = 0.006] and 16% vs. 5% [P = 0.025], respectively). Patients with abnormal CRP, prealbumin, and albumin experienced higher rates of unplanned intensive care unit admission (CRP [27% vs. 8%; P < 0.001], albumin [30% vs. 10%; P < 0.001], prealbumin [29% vs. 9%; P < 0.001]) and increased postoperative mortality at 90 and 180 days. Survival was similar for frail and non-frail patients. In the multivariate analysis, frailty remained an independent risk factor for readmission (hazard ratio, 5.58; 95% confidence interval, 1.39-22.15; P = 0.015). In the post hoc analysis using the pre-cancer RAI score, the postoperative outcomes did not differ between the frail and non-frail patients.

CONCLUSION

In conjunction with preoperative markers of nutrition, the RAI may be used to identify patients who may benefit from additional preoperative risk stratification and increased postoperative follow-up evaluation.

Association of Frailty with Healthcare Utilization for Patients over One Year Following Surgical Evaluation

OBJECTIVE

Characterize the distribution of healthcare utilization associated with pre-operative frailty in the year following evaluation by a surgeon.

SUMMARY BACKGROUND DATA

Frailty is associated with increased morbidity, mortality, and costs for surgical patients. However, the total financial burden for frail patients beyond the index surgery and inpatient stay remains unknown.

METHODS

Prospective cohort assembled from February 2016 to December 2020 within a multi-hospital integrated healthcare delivery and finance system (IDFS), from patients evaluated with the Risk Analysis Index (RAI) of frailty. Inclusion criteria: age greater than 18, valid RAI, membership in the IDFS Health Plan. Data were stratified by frailty and surgical status.

RESULTS

The mean (SD) age was 54.7 (16.1) and 58.2% female of the cohort (n=86,572). For all patients with reimbursement for surgery (n=53,856), frail and very frail patients incurred respective increases of 8% ( P =0.027) and 29% ( P <0.001) on utilization relative to the normal group. Robust patients saw a 52% ( P <0.001) decrease. This pattern was more pronounced in the cohort without surgery (n=32,716). The increase over normal utilization for frail and very frail patients increased to 23% ( P =0.004) and 68% ( P <0.001), respectively. Utilization among robust patients decreased 62% ( P <0.001). Increases among the frail were primarily due to increased inpatient medical and post-acute care services (all P <0.001).

CONCLUSIONS

Patient frailty is associated with increased total healthcare utilization, primarily via increased inpatient medical and post-acute care following surgery. Quantifying these frailty-related financial burdens may inform clinical decision making as well as the design of value-based reimbursement strategies.

A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty

INTRODUCTION

The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers.

METHODS

We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality.

RESULTS

Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality.

CONCLUSIONS

While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer

Importance

Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment.

Objective

To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC.

Design, Setting, and Participants

In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded.

Exposures

Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS).

Main Outcome(s) and Measure(s)

The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL).

Results

Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (β, 2.96; 95% CI, 0.29-5.62).

Conclusions and Relevance

Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.

Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather Than Comorbidities

BACKGROUND

Failure to rescue (FtR), or inpatient death following complication, is a publicly reported hospital quality measure. Previous work has demonstrated significant variation in the proportion of frail patients across hospitals. However, frailty is not incorporated into risk-adjustment algorithms for hospital quality comparisons and risk adjustment is made by comorbidity scores. Our aim was to assess the impact of frailty on FtR quality measurement and as a means of risk adjustment.

METHODS

Patients undergoing open or endovascular aneurysm repair or lower extremity bypass in the Vascular Quality Initiative (VQI) at centers performing ≥ 25 vascular procedures annually (2003-2019) were included. Multivariable logistic regression evaluated in-hospital death using scaled hierarchical modeling clustering at the center level. Center FtR observed/expected ratios were compared with expected values adjusted for either standard comorbidity profiles or frailty as measured by the VQI Risk Analysis Index. Centers were divided into quartiles using VQI-linked American Hospital Association data to describe the hospital characteristics of centers whose ranks changed.

RESULTS

A total of 63,143 patients (213 centers) were included; 1,630 patients (2.58%) were classified as FtR. After accounting for center-level variability, frailty was associated with FtR [scaled odds ratio 1.9 (1.8-2.0), P < 0.001]. The comorbidity-centric and frailty-based models performed similarly in predicting FtR with C-statistics of 0.85 (0.84-0.86) and 0.82 (0.82-0.84), respectively. Overall changes in ranking based on observed/expected ratios were not statistically significant (P = 0.48). High and low performing centers had similar ranking using comorbidity-centric and frailty-based methods; however, centers in the middle of the performance spectrum saw more variability in ranking alterations. Forty nine (23%) of hospitals improved their ranking by five or more positions when using frailty versus comorbidity risk adjustment. The centers in Quartile 4, those who performed the highest number of vascular procedures annually, experience on average a significant improvement in hospital ranking when frailty was used for risk adjustment, whereas centers performing the fewest number of vascular procedures and the lowest proportion of vascular surgery cases annually (Quartile 1) saw a significant worsening of ranking position (all P < 0.05). However, total number of surgical procedures annually, total hospital beds, for-profit status, and teaching hospital status were not significantly associated with changes in rank.

CONCLUSIONS

A simple frailty-adjusted model has similar predictive abilities as a comorbidity-focused model for predicting a common quality metric that influences reimbursement. In addition to distilling the risk-adjustment algorithm to a few variables, frailty can be assessed preoperatively to develop quality improvement efforts for rescuing frail patients. Centers treating a greater proportion of frail patients and those who perform higher volumes of vascular surgery benefit from a risk adjustment strategy based on frailty.