Frailty Is Associated With Increased 30-Day Adverse Events and Hospitalization Costs After Primary Total Hip Arthroplasty

Impact of the hospital frailty risk score on outcomes following primary total elbow arthroplasty

BACKGROUND

The Hospital Frailty Risk Score (HFRS) has demonstrated strong correlation with adverse outcomes in various joint replacement surgeries, yet its applicability in total elbow arthroplasty (TEA) remains unexplored. The purpose of this study is to assess the association between HFRS and postoperative complications following elective primary TEA.

METHODS

The Nationwide Readmissions Database was queried to identify patients undergoing primary TEA from 2016-2020. The HFRS was used to compare medical, surgical, and clinical outcomes of frail vs. nonfrail patients. Mean and relative costs, total hospital length of stay, and discharge disposition for frail and nonfrail patients were also compared.

RESULTS

We identified 2049 primary TEA in frail patients and 3693 in nonfrail patients. Frail patients had increased complication rates including acute respiratory failure (13.6% vs. 1.1%; P < .001), urinary tract infections (12.3% vs. 0.0%; P < .001), transfusions (3.9% vs. 1.1%; P < .001), pneumonia (1.1% vs. 0.2%; P < .001), acute respiratory distress syndrome (3.2% vs. 0.6%; P < .001), sepsis (0.7% vs. 0.1%; P < .001), and hardware failure (1.2% vs. 0.1%; P < .001). Frail patients also experienced higher rates of readmission (37% vs. 25%; P < .001) and death (1.7% vs. 0.2%; P < .001), while being less likely to undergo revision (6.5% vs. 17%; P < .001). Frail patients incurred higher health-care costs ($28,497 vs. $23,377; P < .001) and longer length of stay (5.3 days vs. 2.6 days; P < .001), with reduced likelihood of routine hospital stays (36% vs. 71%; P < .001) and increased utilization of short-term hospitalization (P < .001), care facilities (P < .001), and home health-care services (P < .001).

CONCLUSION

HFRS is a validated indicator of frailty and is strongly associated with increased rates of complications in patients undergoing elective primary TEA. These findings should be considered by orthopedic surgeons when assessing surgical candidacy and discussing treatment options in this at-risk patient population.

Frailty and the incidence of surgical site infection after total hip or knee arthroplasty: A meta-analysis

BACKGROUND

Surgical site infection (SSI) remains a critical postoperative complication after total hip and knee arthroplasty (THA and TKA). Frailty, a condition characterized by decreased physiological reserve and increased vulnerability to stressors, may influence the risk of SSI in these patients. This meta-analysis aims to evaluate the association between frailty and the incidence of SSI following THA or TKA.

METHODS

A systematic search of databases including PubMed, EMBASE, Web of Science, Wanfang, and CNKI was conducted to identify relevant studies. Data were extracted and pooled using a random-effects model to calculate the overall risk ratio (RR) and 95 % confidence intervals (CIs).

RESULTS

A total of ten studies comprising 1,036,787 patients met the inclusion criteria. The meta-analysis revealed that frail patients undergoing THA or TKA had a significantly higher risk of developing SSI compared to non-frail patients (RR = 1.64, 95 % CI: 1.39-1.93, p < 0.001, I2 = 66 %). Subgroup analyses indicated that the type of arthroplasty (hip vs. knee) and the method of frailty assessment did not significantly alter the association. Further subgroup analysis suggested that frailty was significantly associated with a higher incidence of deep SSI including joint infection (RR = 1.77, 95 % CI: 1.27-1.48, p < 0.001), but not the incidence of superficial SSI (RR = 1.57, 95 % CI: 0.45-5.42, p = 0.48). The association between frailty and SSI remains in subgroup of multivariate studies only (RR = 1.56, 95 % CI: 1.34 to 1.80, p < 0.001).

CONCLUSIONS

Frailty is a potential predictor of SSI following TKA/THA.

Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review

OBJECTIVE

Many tools have been used to assess frailty in the perioperative setting. However, no single scale has been shown to be the most effective in predicting postoperative complications. We evaluated the relationship between several frailty scales and the occurrence of complications following different non-cardiac surgeries.

METHODS

This systematic review was registered in PROSPERO (CRD42023473401). The search strategy included PubMed, Google Scholar, and Embase, covering manuscripts published from January 2000 to July 2023. We included prospective and retrospective studies that evaluated frailty using specific scales and tracked patients postoperatively. Studies on cardiac, neurosurgical, and thoracic surgery were excluded because of the impact of underlying diseases on patients' functional status. Narrative reviews, conference abstracts, and articles lacking a comprehensive definition of frailty were excluded.

RESULTS

Of the 2204 articles identified, 145 were included in the review: 7 on non-cardiac surgery, 36 on general and digestive surgery, 19 on urology, 22 on vascular surgery, 36 on spinal surgery, and 25 on orthopedic/trauma surgery. The reviewed manuscripts confirmed that various frailty scales had been used to predict postoperative complications, mortality, and hospital stay across these surgical disciplines.

CONCLUSION

Despite differences among surgical populations, preoperative frailty assessment consistently predicts postoperative outcomes in non-cardiac surgeries.

Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020)

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification.

METHODS

Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Total Hip Arthroplasty

BACKGROUND

Frailty has been associated with poor outcomes and higher costs after primary total hip arthroplasty. However, frailty has not been studied in relation to outcomes after revision total hip arthroplasty (rTHA). This study examined the relationship between the Hospital Frailty Risk Score (HFRS), postoperative outcomes, and cost profiles following rTHA.

METHODS

In this retrospective cohort study, we identified patients who underwent rTHA from January 2017 to November 2019 in the Nationwide Readmission Database. The 3 most frequently reported diagnosis codes for rTHA were then selected: dislocation; mechanical loosening; and infection. We calculated the HFRS for each patient to determine frailty status. We compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients, using multivariate logistic and negative binomial regressions to adjust for covariates. We identified 36,243 total patients who underwent rTHA. Overall, 15,448 patients had a revision for dislocation, 11,062 for mechanical loosening, and 9,733 for infection.

RESULTS

Compared to nonfrail patients, frail patients had higher rates of 30-day readmission, longer length of stay, and higher hospitalization cost. Frail patients had significantly higher rates of 30-day complication and 30-day reoperation.

CONCLUSIONS

Frailty, measured using HFRS, is associated with increased postoperative complications and costs after rTHA. The HFRS has the ability to efficiently identify frail patients at-risk for perioperative complications enabling care teams to better focus optimization interventions on this patient cohort.

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Knee Arthroplasty

BACKGROUND

Frailty can predict adverse outcomes after various orthopaedic procedures, but is not well-studied in revision total knee arthroplasty (rTKA). We investigated the correlation between the Hospital Frailty Risk Score (HFRS) and post-rTKA outcomes.

METHODS

Using the Nationwide Readmissions Database, we identified rTKA patients discharged from January 2017 to November 2019 for the most common diagnoses (mechanical loosening, infection, and instability). Using HFRS, we compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients with multivariate and binomial regressions. The 30-day complication and reoperation rates were compared using univariate analyses. We identified 25,177 mechanical loosening patients, 12,712 infection patients, and 9,458 instability patients.

RESULTS

Frail patients had higher rates of 30-day readmission (7.8 versus 3.7% for loosening, 13.5 versus 8.1% for infection, 8.7 versus 3.9% for instability; P < .01), longer length of stay (4.1 versus 2.4 days for loosening, 8.1 versus 4.4 days for infection, 4.9 versus 2.4 days for instability; P < .01), and greater cost ($32,082 versus $27,582 for loosening, $32,898 versus $28,115 for infection, $29,790 versus $24,164 for instability; P < .01). Frail loosening patients had higher 30-day complication (6.8 versus 2.9%, P < .01) and reoperation rates (1.8 versus 1.2%, P = .01). Frail infection patients had higher 30-day complication rates (14.0 versus 8.3%, P < .01). Frail instability patients had higher 30-day complication (8.0 versus 3.5%, P < .01) and reoperation rates (3.2 versus 1.6%, P < .01).

CONCLUSIONS

The HFRS may identify patients at risk for adverse events and increased costs after rTKA. Further research is needed to determine causation and mitigate complications and costs.

The impact of frailty evaluation on the risk of venous thromboembolism in patients with hip fracture following surgery: a meta-analysis

BACKGROUND

Frailty has been associated with a higher incidence of overall postoperative complications and mortality. However, the influence of frailty on the risk of venous thromboembolism (VTE) in patients with hip fracture following surgery remains unclear. We performed a meta-analysis to systematically evaluate the above association.

METHODS

PubMed, Embase, Cochrane Library, Wanfang and CNKI were searched for relevant observational studies comparing the incidence of postoperative VTE in patients of hip fracture with and without frailty. Data collection, literature searching, and statistical analysis were conducted independently by two authors. Using a heterogeneity-incorporating random-effects model, the results were pooled.

RESULTS

In this meta-analysis, 9509 patients from nine cohort studies were included. Pooled results showed that compared to those without frailty, patients with frailty at admission had a higher incidence of postoperative VTE (odds ratio [OR]: 2.59, 95% confidence interval [CI]: 1.25-5.39, p = 0.01; I2 = 66%). Subgroup analysis suggested the association between frailty and postoperative VTE was more remarkable in studies of patients with frailty prevalence < 50% (OR 6.28, 95% CI 3.31-11.90, p < 0.001; I2 = 8%) as compared to those ≥ 50% (OR 1.30, 95% CI 0.80-2.11, p = 0.28; I2 = 0%; p for subgroup difference < 0.001). Further meta-analyses showed that frailty at baseline was associated with a higher incidence of deep venous thrombosis (OR 3.15, 95% CI 1.33-7.47, p = 0.009; I2 = 59%), but not pulmonary embolism (OR 1.13, 95% CI 0.59-2.16, p = 0.72; I2 = 0%).

CONCLUSION

Frailty is associated with a higher incidence of postoperative VTE in patients with hip fracture.

Association between frailty and clinical post-operative outcomes in patients following hip arthroplasty: a systematic review and meta-analysis

PURPOSE

This research determined the correlation between frailty and post-surgical complications, readmission, re-operation, and mortality in patients with hip arthroplasty through a meta-analysis.

METHODS

We screened PubMed, Web of Science, Embase, and the Cochrane Library for cohort research that explored the correlation between frailty and post-operative complications in patients who underwent hip arthroplasty from inception to August 31, 2022. The Newcastle-Ottawa scale was employed to assess the value of the involved studies. Statistical analyses of the meta-analysis were conducted utilizing Review Manager, version 5.3.

RESULTS

This research involved seven retrospective investigations involving 350,971 patients. The summed findings revealed that frailty is associated with total complications (relative risk [RR] = 3.07, 95% confidence interval [CI]:1.99-4.74), re-operation (RR = 1.98; 95% CI: 1.73-2.28), readmission (RR = 2.04; 95% CI: 1.87-2.22), and 30-day mortality (RR = 2.59, 95% CI: 1.16-5.79). Subgroup and sensitivity analyses revealed that the pooled findings of frailty predict that total complications, re-operation, readmission, and 30-day mortality were stable.

CONCLUSIONS

Pre-operative frailty was correlated with post-surgical complications in patients who underwent hip arthroplasty, including post-operative complications, re-operation, readmission, and 30-day mortality.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier: CRD 42022350781.