Frailty Is Independently Associated With Worse Outcomes After Elective Anatomic Lung Resection

Self-reported exhaustion and a 4-item physical frailty index to predict the incidence of major complications after onco-geriatric surgery

BACKGROUND

The aim of this study was to analyze four pre-operative physical frailty indicators from a geriatric assessment (GA) independently and combined in a physical frailty index, in their ability to predict postoperative 30 d-complications.

MATERIALS AND METHODS

In this secondary analysis of data from the published PERATECS study (ClinicalTrials.gov: NCT01278537), the predictive value of four physical frailty indicators from a defined GA battery was examined with univariable and multivariate logistic regression models in a sample of 493 onco-geriatric surgical patients. The primary endpoint was incidence of major (Clavien-Dindo ≥ grade 2 [CD ≥ 2]) complications within 30 postoperative days. Predictors of the first model included self-reported exhaustion (SRE), body mass index (BMI), Timed Up-and-Go (TUG) and handgrip strength (HGS) independently, and a second model combined these four items as a Physical Frailty Index (4i-PFI). Both regression models were adjusted for age, gender, American Society of Anesthesiologists (ASA) status, tumor sites, duration of surgery time and Mini Nutritional Assessment (MNA) score.

RESULTS

A total of 233 patients (47 %) developed CD ≥ 2 complications. In addition to ASA score, length of surgery, and gynecological and upper gastrointestinal tumor sites, the first model showed that SRE (OR 1.866) predicted CD ≥ 2 complications, but not TUG, BMI and HGS. In the second model, the 4i-PFI predicted CD ≥ 2 complications (OR pre-frail = 1.808, frail = 3.787).

CONCLUSIONS

Physical frailty indicators as SRE revealed a better ability to predict CD ≥ 2 complications than BMI, TUG and HGS. However, prediction of CD ≥ 2 complications was enhanced when these parameters were combined in a novel 4i-PFI.

Off-Pump Coronary Artery Bypass Grafting Does Not Confer Superior Outcomes Among Frail Patients

Off-pump coronary revascularization (OPCAB) has been proposed to benefit patients who are at a greater surgical risk because it avoids the use of extracorporeal circulation. Although, historically, older patients were considered high-risk candidates, recent studies implicate frailty as a more comprehensive measure of perioperative fitness. Yet, the outcomes of OPCAB in frail patients have not been elucidated. Thus, using a national cohort of frail patients, we assessed the impact of OPCAB relative to on-pump coronary revascularization (ONCAB). Patients who underwent first-time elective coronary revascularization were tabulated from the 2010 to 2020 Nationwide Readmissions Database. Frailty was assessed using the previously-validated Johns Hopkins Adjusted Clinical Groups indicator. Multivariable models were used to consider the independent associations between OPCAB and the key outcomes. Of ∼26,529 frail patients, 6,322 (23.8%) underwent OPCAB. After risk adjustment and compared with ONCAB, OPCAB was linked with similar odds of in-hospital mortality but greater likelihood of postoperative cardiac arrest (adjusted odds ratio [AOR] 1.53, confidence interval [CI] 1.13 to 2.07) and myocardial infarction (AOR 1.44, CI 1.23 to 1.69). OPCAB was further associated with greater odds of postoperative infection (AOR 1.22, CI 1.02 to 1.47) but decreased need for blood transfusion (AOR 0.68, CI 0.60 to 0.77). In addition, OPCAB faced a +0.86-day increase in length of stay (CI 0.21 to 1.51) but similar costs (β $1,610, CI -$1,240 to 4,460) relative to ONCAB. Although OPCAB was associated with no difference in mortality compared with ONCAB, it was linked with greater likelihood of postoperative cardiac arrest and myocardial infarction. Our findings demonstrate that ONCAB remains associated with superior outcomes, even in the growing population of frail patients who underwent coronary revascularization.

The risk analysis index is an independent predictor of outcomes after lung cancer resection

BACKGROUND

The Risk Analysis Index (RAI) is a frailty assessment tool based on an accumulation of deficits model. We mapped RAI to data from the Society of Thoracic Surgeons (STS) Database to determine whether RAI correlates with postoperative outcomes following lung cancer resection.

METHODOLOGY/PRINCIPAL FINDINGS

This was a national database retrospective observational study based on data from the STS Database. Study patients underwent surgery 2018 to 2020. RAI was divided into four increasing risk categories. The associations between RAI and each of postoperative complications and administrative outcomes were examined using logistic regression models. We also compared the performance of RAI to established risk indices (American Society of Anesthesiology (ASA) and Charlson Comorbidity Index (CCI)) using areas under the Receiver Operating Characteristic (ROC) curves (AUC). Results: Of 29,420 candidate patients identified in the STS Database, RAI could be calculated for 22,848 (78%). Almost all outcome categories exhibited a progressive increase in marginal probability as RAI increased. On multivariable analyses, RAI was significantly associated with an incremental pattern with almost all outcomes. ROC analyses for RAI demonstrated "good" AUC values for mortality (0.785; 0.748) and discharge location (0.791), but only "fair" values for all other outcome categories (0.618 to 0.690). RAI performed similarly to ASA and CCI in terms of AUC score categories.

CONCLUSIONS/SIGNIFICANCE

RAI is associated with clinical and administrative outcomes following lung cancer resection. However, its overall accuracy as a surgical risk predictor is only moderate and similar to ASA and CCI. We do not recommend routine use of RAI for assessment of individual patient risk for major lung resection.

Impact of Modified Frailty Index on Readmissions Following Surgery for NSCLC

BACKGROUND

 Analyzing the risk factors that predict readmissions can potentially lead to more individualized patient care. The 11-factor modified frailty index is a valuable tool for predicting postoperative outcomes following surgery. The objective of this study is to determine whether the frailty index can effectively predict readmissions within 90 days after lung resection surgery in cancer patients within a single health care institution.

METHODS

 Patients who underwent elective pulmonary resection for nonsmall cell lung cancer (NSCLC) between January 2012 and December 2020 were selected from the hospital's database. Patients who were readmitted after surgery were compared to those who were not, based on their data. Propensity score matching was employed to enhance sample homogeneity, and further analyses were conducted on this newly balanced sample.

RESULTS

 A total of 439 patients, with an age range of 68 to 77 and a mean age of 72, were identified. Among them, 55 patients (12.5%) experienced unplanned readmissions within 90 days, with an average hospital stay of 29.4 days. Respiratory failure, pneumonia, and cardiac issues accounted for approximately 67% of these readmissions. After propensity score matching, it was evident that frail patients had a significantly higher risk of readmission. Additionally, frail patients had a higher incidence of postoperative complications and exhibited poorer survival outcomes with statistical significance.

CONCLUSION

 The 11-item modified frailty index is a reliable predictor of readmissions following pulmonary resection in NSCLC patients. Furthermore, it is significantly associated with both survival and postoperative complications.

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Can modified frailty index predict postoperative complication after lung cancer surgery?

PURPOSE

The impact of the modified frailty index (mFI) on postoperative complications after lung cancer surgery was investigated.

METHODS

Patients who underwent lung cancer surgery in 2017 were included. 30-day postoperative mortality and morbidity were evaluated according to their Clavien-Dindo classification. mFI values are presented as the sum of values of 11 included items. Logistic regression was used to assess the effect of mFI on postoperative severe complication incidence.

RESULTS

Among 190 patients considered, severe postoperative complications (Grade 3 or more) were observed in 30 (16%). No patients died within 30 days of surgery. The incidence of severe complications was 3.6% in patients with mFI of 0, 16.2% in patients with mFI of 1, 23.4% in patients with mFI of 2, and 31.6% in patients with mFI of 3 or more, and was correlated with the grade of mFI. Univariate and multivariate analyses showed that the high mFI was significantly predictive of postoperative complications. Frail patients of mFI ≥ 2 were at 3.0-fold greater risk of severe complications than non-frail patients of mFI 0 or 1.

CONCLUSION

mFI was associated with morbidity after lung cancer surgery. Preoperative frailty assessment and appropriate intervention to frail patients would be required to improve postoperative outcomes.

Factors associated with safe and successful postoperative day 1 discharge after lung operations: a systematic review and meta-analysis

BACKGROUND

A shorter length of stay (LOS) is associated with fewer hospital-acquired adverse conditions and decreased utilization of hospital resources. While modern perioperative care protocols have enabled some ambitious surgical teams to achieve discharge as early as within postoperative day 1 (POD1), most other teams remain cautious about such an approach due to the perceived risk of missing postoperative complications and increased readmission rates. We aimed to identify factors that would help guide surgical teams aiming for safe and successful POD1 discharge after lung resection.

METHODS

We searched the PubMed, Embase, Scopus, Web of Science and CENTRAL databases for articles comparing perioperative characteristics in patients discharged within POD1 (DWPOD1) and after POD1 (DAPOD1) following lung resection. Meta-analysis was performed using a random-effects model.

RESULTS

We included eight retrospective cohort studies with a total of 216,887 patients, of which 22,250 (10.3%) patients were DWPOD1. Our meta-analysis showed that younger patients, those without cardiovascular and respiratory comorbidities, and those with better preoperative pulmonary function are more likely to qualify for DWPOD1. Certain operative factors, such as a minimally invasive approach, shorter operations, and sublobar resections, also favor DWPOD1. DWPOD1 appears to be safe, with comparable 30-day mortality and readmission rates, and significantly less postoperative morbidity than DAPOD1.

CONCLUSIONS

In select patients with a favorable preoperative profile, DWPOD1 after lung resection can be achieved successfully and without increased risk of adverse outcomes such as postoperative morbidity, mortality, or readmissions.

Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation

INTRODUCTION

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking.

METHODS

This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator.

RESULTS

Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge.

CONCLUSIONS

Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.

Racial differences in phenotypic frailty assessment among general thoracic surgery patients

Objectives

The American Association for Thoracic Surgery recommends using frailty assessments to identify patients at higher risk of perioperative morbidity and mortality. We evaluated what patient factors are associated with frailty in a thoracic surgery patient population.

Methods

New patients aged more than 50 years who were evaluated in a thoracic surgery clinic underwent routine frailty screening with a modified Fried's Frailty Phenotype. Differences in demographics and comorbid conditions among frailty status groups were assessed with chi-square and Student t tests. Logistic regressions performed with binomial distribution assessed the association of demographic and clinical characteristics with nonfrail, frail, prefrail, and any frailty (prefrail/frail) status.

Results

The study population included 317 patients screened over 19 months. Of patients screened, 198 (62.5%) were frail or prefrail. Frail patients undergoing thoracic surgery were older, were more likely single or never married, had lower median income, and had lower percent predicted diffusion capacity of the lungs for carbon monoxide and forced expiratory volume during 1 second (all P < .05). More non-Hispanic Black patients were frail and prefrail compared with non-Hispanic White patients (P = .003) and were more likely to score at least 1 point on Fried's Frailty Phenotype (adjusted odds ratio, 3.77; P = .02) when controlling for age, sex, number of comorbidities, median income, diffusion capacity of the lungs for carbon monoxide, and forced expiratory volume during 1 second. Non-Hispanic Black patients were more likely than non-Hispanic White patients to score points for slow gait and low activity (both P < .05).

Conclusions

Non-Hispanic Black patients undergoing thoracic surgery are more likely to score as frail or prefrail than non-Hispanic White patients. This disparity stems from differences in activity and gait speed. Frailty tools should be examined for factors contributing to this disparity, including bias.

Moving beyond frailty: Obesity paradox persists in lung resection

BACKGROUND

The apparent protective effect of high body mass index on postoperative outcomes, termed the "obesity paradox," has been postulated to reflect the relative frailty of patients without obesity. We wanted to examine the independent association between body mass index and outcomes after anatomic lung resection.

METHODS

All adults undergoing elective lung resection for cancer were identified in the 2012-2020 National Surgical Quality Improvement Program. The modified Frailty Index quantified degree of patient frailty. Malnutrition was defined as a preoperative serum albumin <3.5g/dL. Multivariable regressions were used to examine the independent association of body mass index and major adverse events, analyzed as a composite of 30-day mortality, postoperative complications, and unplanned reoperation.

RESULTS

Of an estimated 20,099 patients meeting study criteria, 6,424 (32.0%) had obesity. Relative to others, patients with obesity were significantly younger (49.3 vs 50.3 years), more commonly White (78.1 vs 74.9%), and more frequently frail (modified Frailty Index >1: 35.7 vs 22.5%, all P < .001). There was no significant difference in malnutrition rates (7.6 vs 8.4%, P = .05) or extent of resection between groups. After adjustment, obesity was associated with decreased odds of major adverse events (adjusted odds ratio 0.86, 95% confidence interval 0.78-0.94).

CONCLUSION

The present findings uphold the canonical obesity paradox in anatomic lung resection, despite adjustment for frailty and malnutrition. Further studies are warranted to characterize the nature of this association; however, our results may inform efforts to optimize risk stratification and patient selection for surgical intervention.

Impact of frailty on clinical outcomes and resource utilization of hospitalizations for renal stone surgery

PURPOSE

Frailty is reportedly associated with poorer outcomes among surgical patients. Using a coding-based frailty tool, we investigated the impact of frailty on clinical outcomes and resource utilization for urolithiasis hospitalizations.

METHODS

A cohort study using the 2018 National Inpatient Sample database. All adult elective hospitalizations for urolithiasis were included in the study. The study population was categorized into FRAIL and non-frail (nFRAIL) cohorts using the Johns Hopkins Adjusted Clinical Groups frailty clusters. The association between frailty and clinical and financial outcomes was evaluated using multivariate regression models.

RESULTS

About 1028 (14.9%) out of 6900 total hospitalizations were frail. Frailty was not associated with a significant increase in the odds of in-hospital mortality (adjusted odds ratio (aOR) 1.73, 95% CI 0.15-20.02) or length of hospital stay, but was associated with a lower chance of surgery within 24 h of admission (aOR 0.65, 95% CI 0.48-0.90, P = 0.008). A higher Charlson index was independently associated with an over 100% increase in the odds of in-hospital mortality (aOR 2.091, 95% CI 1.53-2.86, P < 0.001). Frail patients paid $15,993 higher in total hospital costs and had a higher likelihood of non-home discharges (aOR 4.29, 95% CI 2.74-6.71, P < 0.001) and peri-operative complications (aOR 1.77, 95% CI 1.14-2.73, P = 0.01).

CONCLUSION

Frailty was correlated with unfavorable outcomes, except mortality and prolonged hospital stay. Incorporating frailty evaluation into risk models has the potential to enhance patient selection and preparation for urolithiasis intervention.

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.

Association of Preoperative Rehabilitation With Postoperative Length of Hospital Stay for Elderly Lung Cancer Patients

This study aimed to evaluate the effect of preoperative rehabilitation on postoperative hospital stay in elderly lung cancer patients following lung resection. This was a retrospective observational study using the Japanese Diagnosis Procedure Combination database. Data of patients diagnosed between April 2016 and March 2020 were collected. Patients were identified using the International Statistical Classification of Disease and Related Health Problems Version 10-10 codes, C34.0-C34.3 and C34.8. Multilevel linear regression analysis was performed to evaluate the effect of preoperative rehabilitation on the length of hospital stay. A total of 9,393 patients were included in the study. Univariate analysis showed that preoperative rehabilitation was significantly associated with postoperative length of hospital stay (coefficient: -1.61; 95% confidence interval: -2.42, -0.81; P <0.001). In addition, multivariate analysis showed preoperative rehabilitation to be associated with a significant decrease in postoperative length of hospital stay (coefficient=-1.38; 95% confidence interval: -2.19, -0.58; P =0.001). Preoperative rehabilitation may shorten length of hospital stay in elderly patients with lung cancer.

External validation of risk prediction scores in patients undergoing anatomic video-assisted thoracoscopic resection

Background

EuroLung Risk scores were established to predict postoperative morbidity and mortality in patients undergoing anatomic lung resections. We aimed to perform an external validation of the EuroLung scores, which were calculated from data of the European Society of Thoracic Surgeons database, in our video-assisted thoracoscopic surgery cohort.

Methods

All available EuroLung scores were calculated for 718 patients scheduled for anatomic video-assisted thoracoscopic surgery resections between 2009 and 2019. Morbidity and mortality according to the definitions of the EuroLung scores were analyzed in a prospectively maintained database.

Results

Overall observed complication rate was 10.45%. Scores showed weak individual correlation (η = 0.155–0.174). The EuroLung1 app score showed the biggest area under the receiver operative characteristic (ROC) curve with 0.660. Binary logistic regression analysis showed that predicted postoperative forced expiratory volume in 1 s was associated with increased complications in both EuroLung1 and parsimonious EuroLung1 scores. Thirty-day mortality was 0.7% (predicted 1.10–1.40%) and was associated with predicted postoperative forced expiratory volume in 1 s for both EuroLung2 and parsimonious EuroLung2 scores. The EuroLung2 (2016) showed the biggest area under the ROC curve with 0.673. Only a very weak eta correlation between predicted and observed mortality was found for both aggregate EuroLung2, EuroLung2 (2016), EuroLung2 (2019), and parsimonious EuroLung2 (2016) (η = 0.025/0.015/0.011/0.009).

Conclusion

EuroLung scores help to estimate postoperative morbidity. However, even with the highest aggregate EuroLung scores possible only 50% suffer from postoperative morbidity. Although calibration of the scores was acceptable, discrimination between predicted and observed events was poor. Therefore, individual correlation between predicted and observed events is weak. Therefore, EuroLung scores may be best used to compare institutional quality of care to the European Society of Thoracic Surgeons database but should not be used to preclude patients from surgical treatment.