Comparative associations of baseline frailty status and age with postoperative mortality and duration of hospital stay following metastatic brain tumor resection

Hospital frailty risk score predicts high-value care outcomes following brain metastasis resection

OBJECTIVE

Brain metastases (BM) are the most common adult intracranial tumors, representing a significant source of morbidity in patients with systemic malignancy. Frailty indices, including 11- and 5-factor modified frailty indices (mFI-11 and mFI-5), American Society of Anesthesiologists (ASA) physical status classification, and Charlson Comorbidity Index (CCI), have recently demonstrated an important role in predicting high-value care outcomes in neurosurgery. This study aims to investigate the efficacy of the newly developed Hospital Frailty Risk Score (HFRS) on postoperative outcomes in BM patients.

METHODS

Adult patients with BM treated surgically at a single institution were identified (2017-2019). HFRS was calculated using ICD-10 codes, and patients were subsequently separated into low (<5), intermediate (5-15), and high (>15) HFRS cohorts. Multivariate logistic regressions were utilized to identify associations between HFRS and complications, length of stay (LOS), hospital charges, and discharge disposition. Model discrimination was assessed using receiver operating characteristic (ROC) curves.

RESULTS

A total of 356 patients (mean age: 61.81±11.63 years; 50.6 % female) were included. The mean±SD for HFRS, mFI-11, mFI-5, ASA, and CCI were 6.46±5.73, 1.31±1.24, 0.95±0.86, 2.94±0.48, and 8.69±2.07, respectively. On multivariate analysis, higher HFRS was significantly associated with greater complication rate (OR=1.10, p<0.001), extended LOS (OR=1.13, p<0.001), high hospital charges (OR=1.14, p<0.001), and nonroutine discharge disposition (OR=1.12, p<0.001), and comparing the ROC curves of mFI-11, mFI-5, ASA,and CCI, the predictive accuracy of HFRS was the most superior for all four outcomes assessed.

CONCLUSION

The predictive ability of HFRS on BM resection outcomes may be superior than other frailty indices, offering a new avenue for routine preoperative frailty assessment and for managing postoperative expectations.

Neurosurgical resection of multiple brain metastases: outcomes, complications, and survival rates in a retrospective analysis

PURPOSE

This study investigates the outcomes of microsurgical resection of multiple brain metastasis (BMs).

METHODS

This retrospective, monocentric analysis included clinical data from all consecutive BM patients, who underwent simultaneous resection of ≥ 2 BMs between January 2018 and May 2023. Postoperative neurological and functional outcomes, along with perioperative complications, as well as survival data were evaluated.

RESULTS

A total of 47 patients, with a median age of 61 years (IQR 48-69), underwent 73 craniotomies (median 2; range 1-3) for resection of 104 BMs. Among patients, 80.8% presented with symptomatic BMs, causing focal neurological deficits in 53% of cases. Gross total resection was achieved in 87.2% of BMs. Karnofsky Performance Scale (KPS) scores improved in 42.6% of patients, remained unchanged in 46.8%, and worsened in 10.6% after surgery. Perioperative complications were observed in 29.8% of cases, with transient complications occurring in 19.2% and permanent deficits in 10.6%. The 30-days mortality rate was 2.1%. Logistic regression identified eloquent localization (p = 0.036) and infratentorial craniotomy (p = 0.018) as significant predictors of postoperative complications. Concerning overall prognosis, patients with permanent neurological deficits post-surgery (HR 11.34, p = 0.007) or progressive extracranial disease (HR: 4.649; p = 0.006) exhibited inferior survival.

CONCLUSION

Microsurgical resection of multiple BMs leads to clinical stabilization or functional improvement in most patients. Although transient complications do not affect overall survival, the presence of persistent neurological deficits (> 3 months post-surgery) and progressive extracranial disease negatively impact overall survival. This highlights the importance of careful patient selection for resection of multiple BMs.

Baseline Frailty Measured by the Risk Analysis Index and 30-Day Mortality After Surgery for Spinal Malignancy: Analysis of a Prospective Registry (2011-2020)

OBJECTIVE

To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection.

METHODS

SM surgery cases were queried from the American College of Surgeons - National Surgical Quality Improvement Program database (2011-2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, "mortality/hospice") were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 2,235 cases were stratified by RAI score: 0-20, 22.7%; 21-30, 11.9%; 31-40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697-0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001).

CONCLUSION

Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.

Risk Analysis Index and 30-Day Mortality after Brain Tumor Resection: A Multicenter Frailty Analysis of 31,776 Patients from 2012 to 2020

Introduction  The aim of this study was to evaluate the discriminative accuracy of the preoperative Risk Analysis Index (RAI) frailty score for prediction of mortality or transition to hospice within 30 days of brain tumor resection (BTR) in a large multicenter, international, prospective database. Methods  Records of BTR patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program (2012-2020) database. The relationship between the RAI frailty scale and the primary end point (mortality or discharge to hospice within 30 days of surgery) was assessed using linear-by-linear proportional trend tests, logistic regression, and receiver operating characteristic (ROC) curve analysis (area under the curve as C-statistic). Results  Patients with BTR ( N  = 31,776) were stratified by RAI frailty tier: 16,800 robust (52.8%), 7,646 normal (24.1%), 6,593 frail (20.7%), and 737 severely frail (2.3%). The mortality/hospice rate was 2.5% ( n  = 803) and was positively associated with increasing RAI tier: robust (0.9%), normal (3.3%), frail (4.6%), and severely frail (14.2%) ( p  < 0.001). Isolated RAI was a robust discriminatory of primary end point in ROC curve analysis in the overall BTR cohort (C-statistic: 0.74; 95% confidence interval [CI]: 0.72-0.76) as well as the malignant (C-statistic: 0.74; 95% CI: 0. 67-0.80) and benign (C-statistic: 0.71; 95% CI: 0.70-0.73) tumor subsets (all p  < 0.001). RAI score had statistically significantly better performance compared with the 5-factor modified frailty index and chronological age (both p  < 0.0001). Conclusions  RAI frailty score predicts 30-day mortality after BTR and may be translated to the bedside with a user-friendly calculator ( https://nsgyfrailtyoutcomeslab.shinyapps.io/braintumormortalityRAIcalc/ ). The findings hope to augment the informed consent and surgical decision-making process in this patient population and provide an example for future study designs.

Surgical excision and radiotherapy for brain metastasis from colorectal cancer: How frailty and comorbidity indices influence outcome

The incidence of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study aims to identify the clinical prognosticators and evaluate the prognostic validity of common comorbidity indices in patients with BM from CRC. This retrospective single-center study analyzed 93 patients with BM from CRC who received surgical excision and/or radiotherapy. The clinical characteristics and prognostic indices including the 5-item modified frailty index (mFI-5) and prognostic nutritional index (PNI) were calculated from the collected patient data and analyzed. In this study, 66 (71.0%), 10 (10.8%), and 17 (18.3%) patients received whole-brain radiotherapy (WBRT) alone, surgery alone, and surgery plus WBRT, respectively. The median survival of all patients was 3.98 months (IQR: 1.74-7.99). The 2- and 3-year survival rates were 7.4% and 3.7%, respectively. Controlled primary tumor (p = 0.048), solitary BM (p = 0.001), surgery + radiation (p < 0.001), and greater PNI (p = 0.001) were independent predictors of favorable survival. In surgically treated patients, uncontrolled primary tumor (p = 0.006), presence of multiple BM (p < 0.001), and MFI-5 ≥ 2 (p = 0.038) were independent prognosticators. For patients who received WBRT, the presence of two (p = 0.004) or multiple (p < 0.001) BM and PNI (p < 0.001) were independent survival predictors MFI-5, multiple BM, and the status of the primary tumor were independent prognosticators for patients who underwent surgery for CRCBM. For patients who received WBRT, the PNI and the number of BM were independent survival predictors.

Frailty indices in patients undergoing surgical resection of brain metastases: a systematic review

Brain metastases are a relatively common occurrence in patients with primary malignancies, with an incidence ranging from 9 to 17%. Their prevalence has increased due to treatment advancements that have led to improved survival in cancer patients. Frailty has demonstrated the ability to outperform greater patient age in surgical decision-making by predicting postoperative adverse events that include mortality, extended length of hospital stay, non-routine discharge disposition, and postoperative complications. Although predictive models based on frailty have been increasingly utilized in literature, their generalizability remains questionable due to inadequacies in model development and validation. Our systematic review describes development and validation cohorts of frailty indices used in patients undergoing surgical resection of brain metastases and serves as a guide to their incorporation in the outpatient clinical setting. A systematic review of literature was performed using PubMed and Google Scholar. Articles that reported outcomes using frailty indices in patients undergoing surgical resection of brain metastases were included. The Newcastle Ottawa Scale (NOS) was used to assess for risk of bias across individual studies. Studies with NOS > 5 were considered high quality. We identified 238 articles through our search strategy. After a title and abstract screen, followed by a full text review, 9 articles met criteria for inclusion. The 5- and 11-factor modified frailty indices were most frequently utilized (n = 4). Five studies utilized single-hospital databases, and four utilized nationwide databases. Six studies were considered high-quality based on the NOS. Although frailty indices have demonstrated the ability to predict outcomes in patients undergoing surgical resection of brain metastases, further validation of these indices is necessary prior to their incorporation in clinical practice.

Frailty Measured by the Risk Analysis Index Predicts Nonhome Discharge and Mortality After Resection in Refractory Epilepsy: Analysis of 1236 Patients From a Prospective Surgical Registry, 2012 to 2020

BACKGROUND

Risk stratification of epilepsy surgery patients remains difficult. The Risk Analysis Index (RAI) is a frailty measurement that augments preoperative risk stratification.

OBJECTIVE

To evaluate RAI's discriminative threshold for nonhome discharge disposition (NHD) and mortality (or discharge to hospice within 30 days of operation) in epilepsy surgery patients.

METHODS

Patients were queried from the American College of Surgeons-National Surgical Quality Improvement Program database (2012-2020) using diagnosis/procedure codes. Linear-by-linear trend tests assessed RAI's relationship with NHD and mortality. Discriminatory accuracy was assessed by C-statistics (95% CI) in receiver operating characteristic curve analysis.

RESULTS

Epilepsy resections (N = 1236) were grouped into temporal lobe (60.4%, N = 747) and nontemporal lobe (39.6%, N = 489) procedures. Patients were stratified by RAI tier: 76.5% robust (RAI 0-20), 16.2% normal (RAI 21-30), 6.6% frail (RAI 31-40), and 0.8% severely frail (RAI 41 and above). The NHD rate was 18.0% (N = 222) and positively associated with increasing RAI tier: 12.5% robust, 34.0% normal, 38.3% frail, and 50.0% severely frail ( P < .001). RAI had robust predictive discrimination for NHD in overall cohort (C-statistic 0.71), temporal lobe (C-statistic 0.70), and nontemporal lobe (C-statistic 0.71) cohorts. The mortality rate was 2.7% (N = 33) and significantly associated with RAI frailty: 1.1% robust, 8.0% normal, 6.2% frail, and 20.0% severely frail ( P < .001). RAI had excellent predictive discrimination for mortality in overall cohort (C-statistic 0.78), temporal lobe (C-statistic 0.80), and nontemporal lobe (C-statistic 0.74) cohorts.

CONCLUSION

The RAI frailty score predicts mortality and NHD after epilepsy surgery. This is accomplished with a user-friendly calculator: https://nsgyfrailtyoutcomeslab.shinyapps.io/epilepsy/ .

Assessment of the impact of frailty on adverse surgical outcomes in patients undergoing surgery for intracranial tumors using modified frailty index: A systematic review and meta-analysis

BACKGROUND

Modified frailty index (MFI) is an emerging quantitative measure of frailty; however, the quantified risk of adverse outcomes in surgeries for intracranial tumors associated with increasing MFI scores has not been thoroughly reviewed in a comprehensive manner.

METHODS

MEDLINE (PubMed), Scopus, Web of Science, and Embase were searched to identify observational studies on the association between 5 and 11 item-modified frailty index (MFI) and perioperative outcomes for neurosurgical procedures including complications, mortality, readmission, and reoperation rate. Primary analysis pooled all comparisons with MFI scores greater than or equal to 1 versus non-frail participants using mixed-effects multilevel model for each outcome.

RESULTS

In total, 24 studies were included in the review and 19 studies with 114,707 surgical operations were included in the meta-analysis. While increasing MFI scores were associated with worse prognosis for all included outcomes, reoperation rate was only significantly higher in patients with MFI ≥ 3. Among surgical pathologies, glioblastoma was influenced by a greater extent to the impact of frailty on complications and mortality that most other etiologies. In agreement with qualitative evaluation of the included studies, meta-regression did not reveal association between mean age of the comparisons and complications rate.

CONCLUSION

The results of this meta-analysis provides quantitative risk assessment of adverse outcomes in neuro-oncological surgeries with increased frailty. The majority of literature suggests that MFI is a superior and independent predictor of adverse outcomes compared to age.

Baseline frailty status, not advanced patient age, predicts epilepsy surgery outcomes: An analysis of 696 patients from the NSQIP database

OBJECTIVE

Preoperative risk stratification of patients undergoing epilepsy surgery remains challenging. Recently, the efforts to look beyond age alone as an outcomes predictor has resulted in the development of measures of physiological reserve, or 'frailty indices.' The most frequently cited index in neurosurgery is the 11-item or 5-item modified frailty index (mFI11 or mFI-5). The present study aimed to use a large national registry to evaluate the effect of frailty (as measured by mFI-5 versus age on postoperative outcomes of patients undergoing epilepsy surgery.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database, overseen by the American College of Surgeons (ACS), was used to extract data for patients undergoing epilepsy surgery from 2015 to 2019. Univariate and multivariate analyses for age and mFI-5 were performed for the following 30-day outcomes of extended length of hospital stay (eLOS) and non-home discharge (NHD). The effect sizes were summarized by odds ratio and associated 95 % confidence intervals. Receiver operating characteristic (ROC) curve analysis, including area under the curve (AUC), was used to quantify the discrimination.

RESULTS

Univariate and multivariate analyses demonstrated that frailty statuses from mFI-5, not age, were significantly predictive of eLOS and NHD. On ROC curve analysis, mFI-5 was a stronger predictor of eLOS (C = 0.59, 95 % CI 0.54-0.64, p < 0.001) and NHD (C = 0.69, 95 % CI 0.64-0.76, p < 0.001) than age (C = 0.53, 95 % CI 0.48-0.58, p = 0.21 and C = 0.53, 95 % CI 0.46-0.59, p = 0.44, respectively).

CONCLUSION

Frailty, not age, is an independent risk factor for poor postoperative outcomes, particularly eLOS and NHD, in patients undergoing epilepsy surgery. Usage of mFI-5 for preoperative risk stratification of epilepsy surgery patients can help in prognostication.

Higher frailty levels are associated with lower cognitive test scores in a multi-country study: evidence from the study on global ageing and adult health

Background

Frailty has been recognized as a growing issue in older adults, with recent evidence showing that this condition heralds several health-related problems, including cognitive decline. The objective of this work is to determine if frailty is associated with cognitive decline among older adults from different countries.

Methods

We analyzed the baseline the Study on Global Ageing and Adult Health (SAGE), that includes six countries (Ghana, South Africa, Mexico, China, Russia, and India). A cross-section analysis was used to assess how Frailty was related with the Clinical Frailty Scale decision tree, while cognitive decline was evaluated using standardized scores of tests used in SAGE.

Results

A total of 30,674 participants aged 50 years or older were included. There was an association between frailty levels and cognitive performance. For example, women had an inverse relationship between frailty levels and cognitive scores, even when comparing robust category with frailty level 2 (RRR = 0.85; p = 0.41), although the relative risks decrease significantly at level 3 (RRR = 0.66; p = 0.03). When controlling for age, the relative risks between frailty levels 4 to 7 significantly decreased as cognitive performance increased (RRR = 0.46, RRR = 0.52, RRR = 0.44, RRR = 0.32; p < 0.001).

Conclusion

Our results show an association between frailty levels measured in a novel way, and cognitive decline across different cultural settings.

Prognostic Significance of Baseline Frailty Status in Traumatic Spinal Cord Injury

BACKGROUND

Literature evaluating frailty in traumatic spinal cord injury (tSCI) is limited.

OBJECTIVE

To evaluate the prognostic significance of baseline frailty status in tSCI.

METHODS

Patients with tSCI were identified in the National Inpatient Sample from 2015 to 2018 and stratified according to frailty status, which was quantified using the 11-point modified frailty index (mFI).

RESULTS

Among 8825 operatively managed patients with tSCI identified (mean age 57.9 years, 27.6% female), 3125 (35.4%) were robust (mFI = 0), 2530 (28.7%) were prefrail (mFI = 1), 1670 (18.9%) were frail (mFI = 2), and 1500 (17.0%) were severely frail (mFI ≥ 3). One thousand four-hundred forty-five patients (16.4%) were routinely discharged (to home), and 320 (3.6%) died during hospitalization, while 2050 (23.3%) developed a severe complication, and 2175 (24.6%) experienced an extended length of stay. After multivariable analysis adjusting for age, illness severity, trauma burden, and other baseline covariates, frailty (by mFI-11) was independently associated with lower likelihood of routine discharge [adjusted odds ratio (aOR) 0.82, 95% CI 0.77-0.87; P &lt; .001] and development of a severe complication (aOR 1.17, 95% CI 1.12-1.23; P &lt; .001), but not with in-hospital mortality or extended length of stay. Subgroup analysis by age demonstrated robust associations of frailty with routine discharge in advanced age groups (aOR 0.71 in patients 60-80 years and aOR 0.69 in those older than 80 years), which was not present in younger age groups.

CONCLUSION

Frailty is an independent predictor of clinical outcomes after tSCI, especially among patients of advanced age. Our large-scale analysis contributes novel insights into limited existing literature on this topic.

Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report

Background:

The awake craniotomy (AC) procedure allows for safe and maximal resection of brain tumors from highly eloquent regions. However, geriatric patients are often viewed as poor candidates for AC due to age and medical comorbidities. Frailty assessments gauge physiological reserve for surgery and are valuable tools for preoperative decision-making. Here, we present a novel case illustrating how frailty scoring enabled an elderly but otherwise healthy female to undergo successful AC for tumor resection.

Case Description:

A 92-year-old right-handed female with history of hypertension and basal cell skin cancer presented with a 1-month history of progressive aphasia and was found to have a ring-enhancing left frontoparietal mass abutting the rolandic cortex concerning for malignant neoplasm. Frailty scoring with the recalibrated risk analysis index (RAI-C) tool revealed a score of 30 (of 81) indicating low surgical risk. The patient and family were counseled appropriately that, despite advanced chronological age, a low frailty score predicts favorable surgical outcomes. The patient underwent left-sided AC for resection of tumor and experienced immediate improvement of speech intraoperatively. After surgery, the patient was neurologically intact and had an unremarkable postoperative course with significant improvements from preoperatively baseline at follow-up.

Conclusion:

To the best of our knowledge, this case represents the oldest patient to undergo successful AC for brain tumor resection. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric neurosurgery population.

Frailty as a Superior Predictor of Dysphagia and Surgically Placed Feeding Tube Requirement After Anterior Cervical Discectomy and Fusion Relative to Age

Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016-2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.