The impact of perceived frailty on surgeons' estimates of surgical risk

Association Between the Modified Frailty Index and Outcomes Following Lobectomy

INTRODUCTION

Elective thoracic surgery is safe in well-selected elderly patients. The association of frailty with postoperative morbidity in elective-lobectomy patients is understudied. We examined frailty as defined by abbreviated modified frailty index (mFI-5), mFI-11 in the thoracic surgery population, and the correlation between frailty and postoperative complications.

METHODS

We studied outcomes of patients in two cohorts, 2010-2012 and 2013-2019, from the National Surgical Quality Improvement Program (NSQIP) database and used multivariable logistic regression models to predict all postoperative morbidity, mortality, and major morbidity. The mFI-5 could be calculated for all subjects (both 2010-2012, and 2013-2019); the mFI-11 could only be calculated for the 2010-2012 cohort. Patient frailty was defined as mFI≥3 (with either index). We used odds ratios (ORs) to examine associations of preoperative characteristics with postoperative complications and C-statistics to assess overall predictive power.

RESULTS

Complications were less prevalent in the 2013-2019 cohort (17.9% versus 19.5%, P = 0.008). Open lobectomies were more common in the 2010-2012 cohort (53.9% versus 34.6%) and were strongly associated with postoperative morbidity and mortality (ORs >1.5) in both cohorts. Each frailty measure was associated with morbidity and mortality (ORs >1.4) after adjusting for other significant preoperative factors. Models on the 2010-2012 cohort had nearly identical C-statistics using the mFI-11 versus mFI-5 frailty indices (0.6142 versus 0.6139; P > 0.8).

CONCLUSIONS

Frailty, as captured in the mFI-5, is a significant associated factor of postoperative morbidity and mortality following elective lobectomies. As a modifiable risk factor, frailty should be considered in surgical decision-making and when counseling patients regarding perioperative risks.

Gender Bias in Judging Frailty and Fitness for Lung Surgery

BACKGROUND

Disparities in surgical care for lung cancer have been well documented, and unconscious bias may be a source of inequity. We assessed whether gender biases exist when nonclinical decision makers render decisions about major lung surgery.

METHODS

Amazon Mechanical Turk workers, remotely located "crowdworkers" readily available for hire to perform discrete on-demand tasks on the Amazon Mechanical Turk platform, were each shown 4 videos of different standardized patients (SPs) in a clinic setting, 1 video in each energy level (vigorous or frail) and race category (White or Black), randomized to male or female. Workers scored video characteristics and whether they would support the SP's decision to undergo a major lung operation.

RESULTS

A total of 855 workers were recruited. The frail White male SP was more likely to have support to undergo lung surgery than the frail White female SP, while the frail Black male SP was much less likely to have support to undergo lung surgery than the frail Black female SP. There were no significant differences in support for surgery between the vigorous male and female SPs and ratings by male and female workers in their recommendations.

CONCLUSIONS

Biases related to patient gender exist in the general population and affect views on surgery, particularly in the setting of frailty. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations.

Thoracic surgery with geriatric assessment and collaboration can prepare frail older adults for lung cancer surgery

BACKGROUND AND OBJECTIVES

We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients.

METHODS

Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI-CGA < 0.4. A qualitative analysis of geriatric interventions was performed.

RESULTS

Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).

CONCLUSION

Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

Physician Gender Differences in Processing Surgical Risk Features in Videos of Standardized Patients

BACKGROUND

Physician gender differences exist for estimating surgical risk and recommending lung resection. This study assessed gender differences in perceived importance of health characteristics portrayed by standardized patients posing as lung resection candidates.

METHODS

Physicians read a clinical vignette categorized as low, average, or high surgical risk and then viewed a video of a standardized patient exhibiting vigorous, normal, or frail behavior. The relative importance of gait speed, strength, fatigue, age, and weight loss in the videos was scored on a five-point Likert-like scale. Ratings of the importance of each were compared by gender and risk category.

RESULTS

Of 73 participating physicians, 62 were male and 11 were female, 40 were thoracic surgeons, and 33 were cardiothoracic surgical trainees. All video features were scored as very important or somewhat important a majority of the time. Gait speed and strength ratings were strongly correlated (r = 0.76), followed by strength and fatigue (r = 0.52) and gait speed and fatigue (r = 0.51). Female gender was associated with significantly greater odds of rating age as very important (p = 0.040). For weight loss, the differences between genders varied significantly (females consistently rated weight loss as important, whereas ratings for men varied by risk category; p = 0.002 for the interaction).

CONCLUSIONS

Physicians variably rate certain health characteristics of standardized patients as important in making surgical risk estimations. Women and men rate the importance of age and weight loss differently. These findings may help educate physicians to develop more consistent estimates of surgical risk.

Do Estimates of Treatment Risk Based on Clinical Vignettes Differ by Physician Gender?

BACKGROUND

Clinical vignettes are frequently used as instructional and evaluative instruments for physicians. Physicians' gender is a source of unconscious bias in treatment recommendations. This study assessed whether interpretation of information in clinical vignettes differed by physicians' gender as a possible source of unconscious bias.

METHODS

Thoracic surgeons and physicians in cardiothoracic surgical training were asked to provide estimates of major complication rates for lung resection on the basis of anonymized clinical vignettes of patients undergoing lung resection. Vignettes were categorized as low, average, and high risk by using a sum of Charlson Comorbidity Index (possible range, 0 to 37) and a combined physiologic score, EVAD (forced expiratory volume in 1 second, diffusing capacity of lung for carbon monoxide, age; possible range, 0 to 12); participants were not aware of the risk scores or vignette categories. Generalized estimating equation linear regression models were fit with risk scores treated as a continuous independent variable.

RESULTS

A total of 247 physicians (105 practicing surgeons, 142 trainees; 203 men, 44 women) participated in one or more of the studies. Nearly all (103; 98%) of the practicing surgeons rated themselves as competent or expert in lung resection compared with 77 (54%) of the trainees (p < 0.001). Participants' complication estimates mirrored both vignette risk category and combined risk score. There was no significant difference between men and women physicians in their estimates of complication rates.

CONCLUSIONS

Unconscious bias related to physicians' gender is not associated with differential use of information in clinical vignettes. Any possible bias may arise from face-to-face interactions with patients. Research into physicians' and patients' gender differences during such interactions is warranted.

Does Race Influence Risk Assessment and Recommendations for Lung Resection? A Randomized Trial

BACKGROUND

Racial disparities in use of surgical therapy for lung cancer exist in the United States. Videos of standardized patients (SPs) can help identify factors that influence physicians' surgical risk estimation. We hypothesized that physician race and SP race in videos influence surgeon decision making.

METHODS

Four race-neutral clinical vignettes representing lung resection candidates were paired with risk-level concordant short silent videos of SPs. Vignette/video combinations were classified as low or high risk. Trainees and practicing thoracic surgeons read a race-neutral vignette, provided an initial estimate of the percentage risk of major surgical complications, viewed a video randomized to a black or white SP, provided a final estimate of risk, and scored the likelihood that they would recommend operative therapy. Changes in risk estimates were assessed.

RESULTS

Participants included 113 surgeons (38 practicing surgeons, 75 trainees); of these, 76 were white non-Hispanic (67%), and 37 were other self-identified racial categories. Percentage changes between initial and final risk estimates were not significantly related to patient race (p = 0.11) or surgeon race (white versus other; p = 0.52). Videos of black SPs were associated with a similar likelihood of recommending an operation compared with that of videos of white SPs (p = 0.90). Physician race (white versus other) was not related to the likelihood of recommending surgical intervention (p = 0.79).

CONCLUSIONS

Neither patient nor physician race was significantly associated with risk estimation or surgical recommendations. These findings do not provide an explanation for documented racial disparities in lung cancer therapy. Further investigation is needed to identify the mechanism underlying these disparities.

Poor preoperative patient-reported quality of life is associated with complications following pulmonary lobectomy for lung cancer

Objectives

To assess whether quality of life (QOL) was associated with cardiopulmonary complications following pulmonary lobectomy for lung cancer.

Methods

Retrospective analysis of 200 consecutive patients who had pulmonary lobectomy for lung cancer (September 2014-October 2015). QOL was assessed by the self-administration of the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire within 2 weeks before the operation. The individual QOL scales were tested for a possible association with cardiopulmonary complications along with other objective baseline and surgical parameters by univariable and multivariable analyses.

Results

Forty-three patients (21.5%) developed postoperative cardiopulmonary complications; 4 of them died within 30 days (2%). Univariable analysis showed that, compared to patients without complications, those with complications reported a lower global health status (GHS) [59.1; standard deviation (SD) 27.2 vs 69.6; SD 20.6, P  =   0.02], were older (71.2; SD 8.4 vs 67.7; SD 9.4, P  =   0.03), had lower values of forced expiratory volume in one second (FEV1) (83.9; SD 27.2 vs 91.4; SD 20.9), P  =   0.06) and carbon monoxide lung diffusion capacity (DLCO) (67.9; SD 20.9 vs 74.2; SD 17.6, P  =   0.02) and higher performance score (0.76; SD 0.63 vs 0.53; SD 0.64, P  =   0.02). Stepwise logistic regression analysis showed that factors independently associated with cardiopulmonary complications were age [odds ratio (OR) 1.04, 95% CI 1.0-1.09, P  =   0.02] and patient-reported GHS [OR 0.98, 95% confidence interval (CI) 0.96-0.99, P  =   0.006], whereas other objective parameters (i.e. FEV1, DLCO) were not. The best cut-off value for GHS to discriminate patients with complications after surgery was 50 (c-index 0.65, 95% CI 0.58-0.72).

Conclusions

A poor GHS perceived by the patient was associated with postoperative cardiopulmonary morbidity. Patient perceptions and values should be included in the risk stratification process to tailor cancer treatment.

The Influence of Physician and Patient Gender on Risk Assessment for Lung Cancer Resection

BACKGROUND

Women do not receive appropriate surgical therapy for lung cancer as often as men. Patient gender may influence treatment recommendations; less is known about the effect of physician gender on recommendations.

METHODS

Gender-neutral vignettes representing low-risk, average-risk, and high-risk candidates for lung resection were paired with concordant videos of standardized patients (SPs). Cardiothoracic trainees and practicing thoracic surgeons read a vignette, provided an initial estimate of the percentage risk of major adverse events after lung resection, viewed a video (randomized to male or female SP), provided a final estimate of risk, and ranked the importance of the video in the final risk estimate.

RESULTS

Overall, 107 surgeons participated, of whom 90 were men. Initial estimated risks mirrored actual vignette risks: 10.4% ± 9.9 for low risk, 17.6% ± 13.2 for average risk, and 21.0% ± 14.7 for high risk (p < 0.001). After SP videos were viewed and final risk estimates were rendered, there was a significant difference between male and female physicians in the absolute change in estimated risk (p = 0.002), with male physicians having larger changes than female physicians. There was also an effect of SP gender that varied by vignette type (p < 0.001). Increasing video importance scores were directly associated with increasing change in risk scores for average-risk and high-risk vignette/video combinations (p < 0.001 for each).

CONCLUSIONS

Differences in estimating complication risk for lung resection candidates are related to physician and patient gender. This may influence recommendations for surgical treatment. Understanding such differences may help reduce inequities in treatment recommendations.

The Impact of a Frailty Education Module on Surgical Resident Estimates of Lobectomy Risk

BACKGROUND

Frailty is a risk factor for adverse events after surgery. Residents' ability to recognize frailty is underdeveloped. We assessed the influence of a frailty education module on surgical residents' estimates of lobectomy risk.

METHODS

Traditional track cardiothoracic surgery residents were randomly allocated to take an online short course on frailty (experimental group) or to receive no training (control group). Residents read a clinical vignette, made an initial risk estimate of major complications for lobectomy, and rated clinical factors on their importance to their estimates. They viewed a video of a standardized patient portraying the patient in the vignette, randomly selected to exhibit either vigorous or frail behavior, and provided a final risk estimate. After rating five vignettes, they completed a test on their frailty knowledge.

RESULTS

Forty-one residents participated (20 in the experimental group). Initial risk estimates were similar between the groups. The experimental group rated clinical factors as "very important" in their initial risk estimates more often than did the control group (47.6% versus 38.5%; p < 0.001). Viewing videos resulted in a significant change from initial to final risk estimates (frail 50% ± 75% increase, p = 0.008; vigorous 14% ± 32% decrease, p = 0.043). The magnitude of change in risk estimates was greater for the experimental group (10.0 ± 8.1 versus 5.1 ± 7.7; p < 0.001). The experimental group answered more frailty test questions correctly (93.7% versus 75.2%; p < 0.001).

CONCLUSIONS

A frailty education module improved resident knowledge of frailty and influenced surgical risk estimates. Training in frailty may help educate residents in frailty recognition and surgical risk assessment.

Frailty in cardiothoracic surgery: systematic review of the literature

A preoperative surgical risk analysis is necessary and important for predicting clinical and surgical outcomes in a clinical setting. Various tools for evaluating the patient characteristics in order to forecast perioperative clinical outcomes have previously been described; however, an objective and precise preoperative risk assessment has not yet been established. In the last decade, the concept of frailty, which is a geriatric assessment that identifies disabilities and weaknesses in patients, has been used in order to predict clinical mortality and morbidity following invasive surgical interventions because the prevalence of elderly patients among those undergoing surgical interventions is increasing. Since there is currently no single generally accepted clinical definition of frailty, many clinical modalities are needed to evaluate the patients' geriatric activity of daily living. Quantifying the quality of frailty is an evolving challenge for predicting surgical risks preoperatively. In recent years, with the development of transcatheter aortic valve implantation (TAVI), this newly definitive preoperative surgical risk assessment tool, frailty, has become more important and is attracting interest in cardiothoracic surgical settings. Thus, this review summarized current consideration on the preoperative risk analysis by frailty as well as future perspectives and the potential of an ideal frailty risk assessment in cardiothoracic surgery, including the management of elderly patients and high-risk aortic valve stenosis by TAVI.