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Garcia AR, Quan T, Mikula JD, Mologne MS, Best MJ, Thakkar SC. Higher modified frailty index score is associated with 30-day postoperative complications following simultaneous bilateral total knee arthroplasty. Knee 2024; 50:88-95. [PMID: 39128174 DOI: 10.1016/j.knee.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 07/12/2024] [Accepted: 07/20/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND There is no clear consensus regarding patient populations at highest risk for complications from simultaneous bilateral total knee arthroplasty (TKA). The purpose of this study was to determine whether the comorbidities comprising the modified Frailty Index (mFI) were correlated with poor outcomes following simultaneous bilateral TKA. METHODS From 2006 to 2019, patients undergoing bilateral TKA aged 50 years or older were identified in a national database. The 5-item mFI was calculated based on the presence of five comorbidities: diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent functional status. Chi-squared and multivariable regression analyses were used to evaluate the association of mFI scores with postoperative complications. RESULTS The study analyzed 8,776 patients with an average age of 65 years. After adjustment on multivariable regression analysis, compared to patients with a mFI score of 0, those with a score of 1 had an increased risk of pulmonary complication (OR 3.14; p = 0.011), renal problem (OR 12.86; p = 0.022), sepsis complication (OR 2.82; p = 0.024), postoperative transfusion (OR 1.19; p = 0.012), and non-home discharge (OR 1.17; p = 0.002).Patients with a score of 2 compared to 0 had similar complications when compared. These patients had an increased risk of cardiac complication (OR 4.84; p = 0.009) and prolonged hospital stay (OR 4.06; p < 0.001). CONCLUSION Increased mFI scores were associated with significantly higher complication rates in patients undergoing simultaneous bilateral TKA compared to unilateral TKA. Our results can be used to identify which patients may need a staged bilateral TKA or preoperative optimization to safely undergo a simultaneous bilateral TKA. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Theodore Quan
- George Washington School of Medicine and Health Sciences, Washington D.C, USA
| | - Jacob D Mikula
- Steadman Philippon Research Institute, Vail, CO, USA; Department of Orthopaedic Surgery, Johns Hopkins University, Columbia, MD, USA
| | | | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins University, Columbia, MD, USA
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Becerra-Bolaños Á, Hernández-Aguiar Y, Rodríguez-Pérez A. Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review. J Int Med Res 2024; 52:3000605241274553. [PMID: 39268763 PMCID: PMC11406619 DOI: 10.1177/03000605241274553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024] Open
Abstract
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.
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Affiliation(s)
- Ángel Becerra-Bolaños
- Department of Anesthesiology, Intensive Care and Pain Medicine, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical and Surgical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Yanira Hernández-Aguiar
- Department of Anesthesiology, Intensive Care and Pain Medicine, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical and Surgical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Aurelio Rodríguez-Pérez
- Department of Anesthesiology, Intensive Care and Pain Medicine, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical and Surgical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Fedorka CJ, Srikumaran U, Abboud JA, Liu H, Zhang X, Kirsch JM, Simon JE, Best MJ, Khan AZ, Armstrong AD, Warner JJP, Fares MY, Costouros J, O'Donnell EA, Beck da Silva Etges AP, Jones P, Haas DA, Gottschalk MB. Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data. J Am Acad Orthop Surg 2024; 32:e741-e749. [PMID: 38452268 DOI: 10.5435/jaaos-d-23-00572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001). DISCUSSION TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE Level III, therapeutic retrospective cohort study.
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Affiliation(s)
- Catherine J Fedorka
- From the Department of Orthopaedic Surgery, Harvard Medical School, Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA (Simon, Warner, and O'Donnell), Avant-garde Health, Boston, MA (Liu, Zhang, Beck da Silva Etges, Jones, and Haas), Department of Orthopaedic Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD (Srikumaran and Best), Department of Orthopaedics and Rehabilitation, Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA (Armstrong), Department of Orthopedics, Northwest Permanente PC, Portland, OR (Khan), Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ (Fedorka), Department of Orthopaedic Surgery, Emory University, Atlanta, GA (Gottschalk), Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA (Kirsch), California Shoulder Institute, Menlo Park, CA (Costouros), and the Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA (Abboud and Fares)
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Seibold BT, Quan T, Das A, Thakkar S, Tabaie S, Moschetti W. Modified frailty index can help predict complications following tibial plateau fracture fixation: a NSQIP study involving 2213 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3281-3287. [PMID: 39138670 DOI: 10.1007/s00590-024-04070-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE The 5-item modified frailty index (mFI-5) has been established as a reliable indicator of poor postoperative outcomes following a variety of orthopaedic procedures. This study aims to determine whether the mFI-5 can be used by surgeons to predict the likelihood of postoperative complications in patients undergoing open reduction internal fixation (ORIF) for tibial plateau fractures. METHODS From 2006 to 2019, patients aged 50 years or older undergoing ORIF for tibial plateau fracture were identified in the National Surgical Quality Improvement Program database. The mFI-5 was calculated based on the sum of the presence of 5 conditions: diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent functional status. Chi-squared tests and multivariable regression analysis were used to evaluate the association of different mFI-5 scores with postoperative complications. RESULTS The study analyzed 2213 patients with an average age of 63 years. Multivariable regression analysis demonstrated that in comparison to patients with a mFI-5 score of 0, those with a score of 1 had an increased risk of prolonged hospital stay (OR 1.31) and discharge to a non-home location (OR 1.50) while those with a score of 2 or greater were at an increased risk of readmission (OR 2.30), wound complication (OR 5.37), pulmonary complication (OR 4.56), urinary tract infection (OR 4.79), prolonged hospital stay (OR 1.89), and discharge to a non-home location (OR 3.01). CONCLUSION The mFI-5 is a reliable instrument for determining the likelihood of postoperative complications following ORIF for tibial plateau fracture repair. LEVEL OF EVIDENCE III.
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Affiliation(s)
- B Tanner Seibold
- Department of Orthopaedic Surgery, School of Medicine and Health Sciences, The George Washington University, 2300 I St NW, Washington, DC, 20052, USA.
| | - Theodore Quan
- Department of Orthopaedic Surgery, School of Medicine and Health Sciences, The George Washington University, 2300 I St NW, Washington, DC, 20052, USA
| | - Avilash Das
- Department of Orthopaedic Surgery, School of Medicine and Health Sciences, The George Washington University, 2300 I St NW, Washington, DC, 20052, USA
| | - Savyasachi Thakkar
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Tabaie
- Department of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC, USA
| | - Wayne Moschetti
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Yamaguchi Y, Matsumura Y, Fujii M, Ide S, Sakai T, Nagamine S, Eto S, Shimazaki T, Tajima T, Mawatari M. Age-adjusted 5-factor modified frailty index as a valuable tool for patient selection in bilateral simultaneous total knee arthroplasty. Sci Rep 2024; 14:14598. [PMID: 38918560 PMCID: PMC11199499 DOI: 10.1038/s41598-024-65719-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/24/2024] [Indexed: 06/27/2024] Open
Abstract
Although bilateral simultaneous total knee arthroplasty (BSTKA) is an effective treatment for bilateral knee osteoarthritis, safety concerns and lack of precise patient selection criteria persist. The purpose of this retrospective study was to determine the complication rate and the role of frailty in patient selection for BSTKA. We analyzed data from 434 patients who underwent BSTKA between February 2012 and January 2021, examining demographic factors and preoperative blood test results. Complications occurred in 77 patients (18%), with anemia requiring transfusion being the most common (26 patients, 5.9%). In the univariate analysis, age ≥ 75 years, age-adjusted Charlson Comorbidity Index ≥ 5, age-adjusted 5-factor modified Frailty Index (aamFI-5) ≥ 3, hemoglobin ≤ 11.0 g/dL, albumin ≤ 3.5 g/dL, estimated glomerular filtration rate < 45 ml/dl/1.73 m2, and D-dimer ≥ 2.0 μg/mL contributed to postoperative complications (p < 0.05). Multivariate analysis identified aamFI-5 ≥ 3 as an independent risk factor (p = 0.002). Our findings underscore the practical utility of aamFI-5 in predicting complications after BSTKA, providing valuable guidance to surgeons in the selection of BSTKA candidates and ultimately improving clinical outcomes.
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Affiliation(s)
- Yuichi Yamaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yosuke Matsumura
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Masanori Fujii
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Shuya Ide
- Tsuruta Orthopaedic Clinic, Saga, Japan
| | - Tatsuya Sakai
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Satomi Nagamine
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Shuichi Eto
- Department of Orthopaedic Surgery, National Hospital Organization Saga National Hospital, Saga, Japan
| | | | - Tomonori Tajima
- Department of Orthopaedic Surgery, JCHO Saga Central Hospital, Saga, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Ibelli TJ, Alerte E, Akhavan A, Liu H, Kuruvilla A, Katz A, Etigunta S, Taub PJ. The Modified Five-Item Frailty Index to Predict Hand and Wrist Surgical Repair Postoperative Outcomes: An ACS-NSQIP Analysis of 11 369 Patients. Hand (N Y) 2024; 19:433-441. [PMID: 36194006 PMCID: PMC11067845 DOI: 10.1177/15589447221124270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hand and wrist injuries can cause painful, everyday obstacles for patients. Carefully indexing preoperative patient health conditions may better inform surgical care, leading to improved postoperative outcomes. The purpose of the present study is to evaluate if the Modified Five-Item Frailty Index (mFI-5) can accurately predict postoperative complications for hand and wrist surgical repair. METHODS A retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program database was conducted to investigate patients who underwent hand and wrist surgical repair from January 2013 to December 2019. Patient demographics, comorbidities, surgical logistics, and 30-day readmission due to postoperative complications were extracted. Surgical risk proxies including the mFI-5, age, body mass index (BMI), smoking status within 1 year, the Modified Charlson Comorbidity Index (mCCI), comorbidities, and American Society of Anaesthesiologists Physical Status Classification (ASA class) were calculated. RESULTS A total of 11 369 patients were included. Thirty-day readmission for total postoperative complications (n = 258) was significantly associated with all surgical risk proxies. However, age, mFI-5 > 2, mCCI > 2, comorbidities > 1, and ASA class 2/3 had the highest statistical significance (P = <.001). Thirty-day readmission rates for surgical site infections (n = 118) had the highest statistical significance with age, BMI, mFI-5 > 2, and ASA class 2/3 (P = <.001). A Clavien-Dindo score > 1 (n = 224) had the highest statistical significance with age, mCCI > 2, comorbidity of 1, and an ASA class 3 (P = <.001). CONCLUSIONS The mFI-5 may have value in predicting 30-day readmission due to postoperative complications after surgical repair of hand and wrist injuries.
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Affiliation(s)
| | - Eric Alerte
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Helen Liu
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Abigail Katz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suhas Etigunta
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter J. Taub
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Chau CSM, Ee SCE, Huang X, Siow WS, Tan MBH, Sim SKR, Chang TY, Kwok KM, Ng K, Yeo LF, Lim A, Sim LE, Conroy S, Rosario BH. Frailty-aware surgical care: Validation of Hospital Frailty Risk Score (HFRS) in older surgical patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:90-100. [PMID: 38920233 DOI: 10.47102/annals-acadmedsg.2023221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Frailty has an important impact on the health outcomes of older patients, and frailty screening is recommended as part of perioperative evaluation. The Hospital Frailty Risk Score (HFRS) is a validated tool that highlights frailty risk using 109 International Classification of Diseases, 10th revision (ICD-10) codes. In this study, we aim to compare HFRS to the Charlson Comorbidity Index (CCI) and validate HFRS as a predictor of adverse outcomes in Asian patients admitted to surgical services. Method A retrospective study of electronic health records (EHR) was undertaken in patients aged 65 years and above who were discharged from surgical services between 1 April 2022 to 31 July 2022. Patients were stratified into low (HFRS <5), interme-diate (HFRS 5-15) and high (HFRS >15) risk of frailty. Results Those at high risk of frailty were older and more likely to be men. They were also likely to have more comorbidities and a higher CCI than those at low risk of frailty. High HFRS scores were associated with an increased risk of adverse outcomes, such as mortality, hospital length of stay (LOS) and 30-day readmission. When used in combination with CCI, there was better prediction of mortality at 90 and 270 days, and 30-day readmission. Conclusion To our knowledge, this is the first validation of HFRS in Singapore in surgical patients and confirms that high-risk HFRS predicts long LOS (≥7days), increased unplanned hospital readmissions (both 30-day and 270-day) and increased mortality (inpatient, 10-day, 30-day, 90-day, 270-day) compared with those at low risk of frailty.
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Affiliation(s)
| | | | - Xiaoting Huang
- Department of Geriatric Medicine, Changi General Hospital, Singapore
| | - Wei Shyan Siow
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Michelle Bee Hua Tan
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | | | | | - Kah Meng Kwok
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
| | - Kangqi Ng
- Department of Internal Medicine, Changi General Hospital, Singapore
| | - Li Fang Yeo
- Department of Internal Medicine, Changi General Hospital, Singapore
| | - Aileen Lim
- Health Systems Intelligence, Changi General Hospital, Singapore
| | | | - Simon Conroy
- University College London, London, United Kingdom
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Khan M, Patnaik R, Lue M, Dao Campi H, Montorfano L, Sarmiento Cobos M, Valera RJ, Rosenthal RJ, Wexner SD. Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair. Am Surg 2024; 90:207-215. [PMID: 37632725 DOI: 10.1177/00031348231198102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2023]
Abstract
BACKGROUND The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs. METHODS Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility. RESULTS 2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis. CONCLUSIONS Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.
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Affiliation(s)
- Mustafa Khan
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ronit Patnaik
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Melinda Lue
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Haisar Dao Campi
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Lisandro Montorfano
- Department of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Roberto J Valera
- Department of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Raul J Rosenthal
- Department of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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Han BL, Ma LZ, Han SL, Mi YC, Liu JY, Sheng ZH, Wang HF, Tan L. Explore the Role of Frailty as a Contributor to the Association Between AT(N) Profiles and Cognition in Alzheimer's Disease. J Alzheimers Dis 2024; 100:1333-1343. [PMID: 39093070 DOI: 10.3233/jad-231489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Background The relationship between Alzheimer's disease (AD)-related pathology and cognition was not exactly consistent. Objective To explore whether the association between AD pathology and cognition can be moderated by frailty. Methods We included 1711 participants from the Alzheimer's Disease Neuroimaging Initiative database. Levels of cerebrospinal fluid amyloid-β, p-tau, and t-tau were identified for AD-related pathology based on the amyloid-β/tau/neurodegeneration (AT[N]) framework. Frailty was measured using a modified Frailty Index-11 (mFI-11). Regression and interaction models were utilized to assess the relationship among frailty, AT(N) profiles, and cognition. Moderation models analyzed the correlation between AT(N) profiles and cognition across three frailty levels. All analyses were corrected for age, sex, education, and APOEɛ4 status. Results In this study, frailty (odds ratio [OR] = 1.71, p < 0.001) and AT(N) profiles (OR = 2.00, p < 0.001) were independently associated with cognitive status. The model fit was improved when frailty was added to the model examining the relationship between AT(N) profiles and cognition (p < 0.001). There was a significant interaction between frailty and AT(N) profiles in relation to cognitive status (OR = 1.12, pinteraction = 0.028). Comparable results were obtained when Mini-Mental State Examination scores were utilized as the measure of cognitive performance. The association between AT(N) profiles and cognition was stronger with the levels of frailty. Conclusions Frailty may diminish patients' resilience to AD pathology and accelerate cognitive decline resulting from abnormal AD-related pathology. In summary, frailty contributes to elucidating the relationship between AD-related pathology and cognitive impairment.
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Affiliation(s)
- Bao-Lin Han
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Ling-Zhi Ma
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Shuang-Ling Han
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Yin-Chu Mi
- Department of Neurology, Qingdao Municipal Hospital, Dalian Medical University, Qingdao, China
| | - Jia-Yao Liu
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Ze-Hu Sheng
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Hui-Fu Wang
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Department of Neurology, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
| | - Lan Tan
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Department of Neurology, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
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10
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Ling K, Achonu JU, Martino R, Liu SH, Komatsu DE, Wang ED. Six-Item Modified Frailty Index independently predicts complications following total shoulder arthroplasty. JSES Int 2024; 8:99-103. [PMID: 38312266 PMCID: PMC10837715 DOI: 10.1016/j.jseint.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background In the realm of orthopedic surgery, frailty has been associated with higher rates of complications following total hip and total knee arthroplasties. Among various measures of frailty, the Six-Item Modified Frailty Index (MF-6) has recently gained popularity as a predictor for postoperative complications. The purpose of this study was to investigate MF-6 as a predictor for early postoperative complications in the elderly patient population following total shoulder arthroplasty (TSA). Methods The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Patient demographics and comorbidities were compared between cohorts using bivariate logistic regression analysis. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between the MF-6 score and postoperative complications. Results Of total, 9228 patients were included in this study: 8764 (95.0%) had MF-6 <3, and 464 (5.0%) patients had MF-6 ≥3. Multivariate analysis found MF-6 ≥3 to be independently associated with higher rates of urinary tract infection (odds ratio [OR]: 2.79, 95% confidence interval [CI]: 1.49-5.23; P = .001), blood transfusion (OR: 1.53, 95% CI: 1.01-2.32; P = .045), readmission (OR: 1.58, 95% CI: 1.06-2.35; P = .024), and non-home discharge (OR: 2.60, 95% CI: 2.08-3.25; P < .001). Conclusion A high MF-6 score (≥3) in patients aged 65 and older is independently associated with higher rates of urinary tract infection, blood transfusion, readmission, and non-home discharge following TSA. The MF-6 score can be easily calculated preoperatively and may allow for better preoperative risk stratification.
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Affiliation(s)
- Kenny Ling
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Justice U. Achonu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Robert Martino
- Department of Orthopaedics, SUNY Upstate Norton College of Medicine, Syracuse, NY, USA
| | - Steven H. Liu
- Department of Orthopaedics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
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Hassan AM, Paidisetty P, Ray N, Govande JG, Nelson JA, Mehrara BJ, Butler CE, Mericli AF, Selber JC. Frail but Resilient: Frailty in Autologous Breast Reconstruction is Associated with Worse Surgical Outcomes but Equivalent Long-Term Patient-Reported Outcomes. Ann Surg Oncol 2024; 31:659-671. [PMID: 37864119 DOI: 10.1245/s10434-023-14412-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/19/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction. PATIENTS AND METHODS We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort. RESULTS We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011). CONCLUSION Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.
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Affiliation(s)
- Abbas M Hassan
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Praneet Paidisetty
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nicholas Ray
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Janhavi G Govande
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jonas A Nelson
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Department of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles E Butler
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Zamanzadeh RS, Seilern Und Aspang JRM, Schwartz AM, Martin JR, Premkumar A, Wilson JM. Age-Adjusted Modified Frailty Index Predicts 30-Day Complications and Mortality in Aseptic Revision Total Hip and Knee Arthroplasty. J Arthroplasty 2024; 39:198-205. [PMID: 37380143 DOI: 10.1016/j.arth.2023.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND The age-adjusted modified frailty index (aamFI) has been demonstrated to effectively predict postoperative complications and healthcare resource utilization in patients undergoing primary total joint arthroplasty. The purpose of this study was to evaluate the applicability of aamFI in patients undergoing aseptic revision total hip (rTHA) and knee arthroplasty (rTKA). METHODS A national database was queried for patients undergoing aseptic rTHA and rTKA from 2015 to 2020. A total of 13,307 rTHA and 18,762 rTKA cases were identified. The aamFI was calculated by adding 1 additional point for age ≥73 years to the previously described 5-item modified frailty index (mFI-5). The area under the curve was calculated and compared to compare predictive accuracy between mFI-5 and aamFI. Logistic regression was used to investigate the relationship between aamFI and 30-day complications. RESULTS The incidence of incurring any (≥1) complication increased from 15% for aamFI 0 to 45% for aamFI ≥5 after rTHA and from 5 to 55% after rTKA. Patients who had an aamFI ≥3 (reference aamFI = 0) had increased odds (rTHA: odds ratio (OR) 3.5, 95% confidence interval (CI) 2.9 to 4.1, P < .001; rTKA: OR 4.2, 95% CI 4.4 to 5.1, P < .001) of incurring at least 1 complication. The aamFI, compared to mFI-5, was a more accurate predictor of any complication (rTHA P < .001; rTKA P < .001) and 30-day mortality (rTHA P < .001; rTKA P < .003). CONCLUSION The aamFI is an excellent predictor of complications in patients undergoing rTHA and rTKA. The addition of chronological age to the previously described mFI-5 improves the predictive value of this simple metric.
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Affiliation(s)
- Ryan S Zamanzadeh
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Andrew M Schwartz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ajay Premkumar
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Gordon AM, Conway CA, Sheth BK, Magruder ML, Choueka J. The 5-Item Modified Frailty Index for Risk Stratification of Patients Undergoing Total Elbow Arthroplasty. Hand (N Y) 2023; 18:1307-1313. [PMID: 35695171 PMCID: PMC10617473 DOI: 10.1177/15589447221093728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty, quantified using the 5-item modified frailty index (mFI-5), has been shown to predict adverse outcomes in orthopaedic surgery. The utility in total elbow arthroplasty (TEA) patients is unclear. We evaluated if increasing frailty would correlate with worse postoperative outcomes. METHODS A retrospective assessment of patients in the American College of Surgeons National Surgery Quality Improvement Program undergoing primary TEA was performed. The mFI-5 was calculated by assigning 1 point for each comorbidity (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status). Poisson regression was used to evaluate mFI-5 scores on complications, length of stay (LOS), and adverse discharge. A significance threshold was at P < .05. RESULTS In total, 609 patients were included; 34.5% (n = 210) were not frail (mFI = 0), 44.0% (n = 268) were slightly frail (mFI = 1), and 21.5% (n = 131) were frail (mFI ≥ 2). As mFI score increased from 0 to ≥ 2, the following rates increased: any complication (9.0%-19.8%), major complication (11.0%-20.6%), cardiac complication (0.0%-2.3%), hematologic complication (3.3%-9.2%), adverse discharge (2.9%-22.9%), and LOS from 2.08 to 3.97 days (all P < .048). Following adjustment, Poisson regression demonstrated patients with a mFI ≥ 2 had increased risk of major complication (risk ratio [RR]: 2.13; P = .029), any complication (RR: 2.49; P = .032), Clavien-Dindo IV complication (RR: 5.53; P = .041), and adverse discharge (RR: 5.72; P < .001). CONCLUSIONS Frailty is not only associated with longer hospitalizations, but more major complications and non-home discharge. The mFI-5 is a useful risk stratification that may assist in decision-making for TEA.
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Clements NA, Gaskins JT, Martin RCG. Predictive Ability of Comorbidity Indices for Surgical Morbidity and Mortality: a Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:1971-1987. [PMID: 37430092 DOI: 10.1007/s11605-023-05743-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/27/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Several contemporary risk stratification tools are now being used since the development of the Charlson Comorbidity Index (CCI) in 1987. The purpose of this systematic review and meta-analysis was to compare the utility of commonly used co-morbidity indices in predicting surgical outcomes. METHODS A comprehensive review was performed to identify studies reporting an association between a pre-operative co-morbidity measurement and an outcome (30-day/in-hospital morbidity/mortality, 90-day morbidity/mortality, and severe complications). Meta-analysis was performed on the pooled data. RESULTS A total of 111 included studies were included with a total cohort size 25,011,834 patients. The studies reporting the 5-item Modified Frailty Index (mFI-5) demonstrated a statistical association with an increase in the odds of in-hospital/30-day mortality (OR:1.97,95%CI: 1.55-2.49, p < 0.01). The pooled CCI results demonstrated an increase in the odds for in-hospital/30-day mortality (OR:1.44,95%CI: 1.27-1.64, p < 0.01). Pooled results for co-morbidity indices utilizing a scale-based continuous predictor were significantly associated with an increase in the odds of in-hospital/30-day morbidity (OR:1.32, 95% CI: 1.20-1.46, p < 0.01). On pooled analysis, the categorical results showed a higher odd for in-hospital/30-day morbidity (OR:1.74,95% CI: 1.50-2.02, p < 0.01). The mFI-5 was significantly associated with severe complications (Clavien-Dindo ≥ III) (OR:3.31,95% CI:1.13-9.67, p < 0.04). Pooled results for CCI showed a positive trend toward severe complications but were not significant. CONCLUSION The contemporary frailty-based index, mFI-5, outperformed the CCI in predicting short-term mortality and severe complications post-surgically. Risk stratification instruments that include a measure of frailty may be more predictive of surgical outcomes compared to traditional indices like the CCI.
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Affiliation(s)
- Noah A Clements
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, 315 E. Broadway, Louisville, KY, 40292, USA
| | - Jeremy T Gaskins
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, 315 E. Broadway, Louisville, KY, 40292, USA
| | - Robert C G Martin
- The Hiram C. Polk, Jr., MD Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, 315 E. Broadway, Louisville, KY, 40292, USA.
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Zhang D, Ostergaard PJ, Hall MJ, Shoji M, Earp BE. The Relationship Between Frailty and Functional Outcomes, Range of Motion, and Reoperation After Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture. Orthopedics 2023; 46:274-279. [PMID: 37018624 DOI: 10.3928/01477447-20230330-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse total shoulder arthroplasty (rTSA) for proximal humerus fracture. We performed a retrospective study of 153 patients who underwent rTSA for proximal humerus fracture at two level 1 trauma centers from 2003 to 2018 with minimum 2-year follow-up. Frailty was assessed using the modified 5-item frailty index (mFI). The primary outcome variable was the American Shoulder and Elbow Surgeons (ASES) shoulder score at minimum 2-year follow-up. The secondary outcome variables were the Shoulder Pain and Disability Index (SPADI), the Shoulder Subjective Value (SSV), the 0 to 10 numeric rating scale (NRS) pain score, surgical complication, and reoperation. Bivariate comparisons were made between mFI and outcome variables. The mean age of the 153 patients was 70 years, and 76% were women. Forty patients (26%) had a mFI score of 0, 65 patients (42%) had a mFI score of 1, 40 patients (26%) had a mFI score of 2, and 8 patients (5%) had a mFI score of 3. Twenty-seven patients (18%) had complications, and 21 patients (14%) underwent reoperation. At minimum 2-year follow-up, mFI was not associated with ASES shoulder score, SPADI, SPADI pain or disability subscales, SSV, NRS pain score, active and passive shoulder forward flexion, abduction, and external rotation, complication, or reoperation. Provided they survive the initial physiologic insults of trauma and surgery, patients with higher mFI scores treated with rTSA for proximal humerus fracture can expect similar medium-term restoration of shoulder function. [Orthopedics. 2023;46(5):274-279.].
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Seilern Und Aspang J, Zamanzadeh RS, Schwartz AM, Premkumar A, Hussain ZB, Boissonneault A, Martin JR, Wilson JM. The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Sex and Race: Is Frailty Equitably Detrimental? J Arthroplasty 2023; 38:1668-1675. [PMID: 36868329 DOI: 10.1016/j.arth.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Whether frailty impacts total hip arthroplasty (THA) patients of different races or sex equally is unknown. This study aimed to assess the influence of frailty on outcomes following primary THA in patients of differing race and sex. METHODS This is a retrospective cohort study utilizing a national database (2015-2019) to identify frail (≥2 points on the modified frailty index-5) patients undergoing primary THA. One-to-one matching for each frail cohort of interest (race: Black, Hispanic, Asian, versus White (non-Hispanic), respectively; and sex: men versus women) was performed to diminish confounding. The 30-day complications and resource utilizations were then compared between cohorts. RESULTS There was no difference in the occurrence of at least 1 complication (P > .05) among frail patients of differing race. However, frail Black patients had increased odds of postoperative transfusion (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.02-1.77), deep vein thrombosis (OR: 2.61, 95% CI: 1.08-6.27), as well as >2-day hospitalization and nonhome discharge (P < .001). Frail women had higher odds of having at least 1 complication (OR: 1.67, 95% CI: 1.47-1.89), nonhome discharge, readmission, and reoperation (P < .05). Contrarily, frail men had higher 30-day cardiac arrest (0.2% versus 0.0%, P = .020) and mortality (0.3 versus 0.1%, P = .002). CONCLUSION Frailty appears to have an overall equitable influence on the occurrence of at least 1 complication in THA patients of different races, although different rates of some individual, specific complications were identified. For instance, frail Black patients experienced increased deep vein thrombosis and transfusion rates relative to their non-Hispanic White counterparts. Contrarily, frail women, relative to frail men, have lower 30-day mortality despite increased complication rates.
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Affiliation(s)
| | - Ryan S Zamanzadeh
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Schwartz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Adam Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Solano QP, Howard R, Mullens CL, Ehlers AP, Delaney LD, Fry B, Shen M, Englesbe M, Dimick J, Telem D. The impact of frailty on ventral hernia repair outcomes in a statewide database. Surg Endosc 2023; 37:5603-5611. [PMID: 36344897 PMCID: PMC9640794 DOI: 10.1007/s00464-022-09626-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/11/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Preoperative frailty is a strong predictor of postoperative morbidity in the general surgery population. Despite this, there are a paucity of research examining the effect of frailty on outcomes after ventral hernia repair (VHR), one of the most common abdominal operations in the USA. We examined the association of frailty with short-term postoperative outcomes while accounting for differences in preoperative, operative, and hernia characteristics. METHODS We retrospectively reviewed the Michigan Surgery Quality Collaborative Hernia Registry (MSQC-HR) for adult patients who underwent VHR between January 2020 and January 2022. Patient frailty was assessed using the validated 5-factor modified frailty index (mFI5) and categorized as follows: no (mFI5 = 0), moderate (mFI5 = 1), and severe frailty (mFI5 ≥ 2). Our primary outcome was any 30-day complication. Multivariable logistic regression was used to evaluate the association of frailty with outcomes while controlling for patient, operative, and hernia variables. RESULTS A total of 4406 patients underwent VHR with a mean age (SD) of 55 (15) years, 2015 (46%) females, and 3591 (82%) white patients. The mean (SD) BMI of the cohort was 33 (8) kg/m2. A total of 2077 (47%) patients had no frailty, 1604 (36%) were moderately frail, and 725 (17%) were severely frail. The median hernia size (interquartile range) was 2.5 cm (1.5-4.0 cm). Severe frailty was associated with increased odds of any complication (adjusted Odds Ratio (aOR) 3.12, 95% CI 1.78-5.47), serious complication (aOR 5.25, 95% CI 2.17-13.19), SSI (aOR 3.41, 95% CI 1.58-7.34), and post-discharge adverse events (aOR 1.70, 95% CI 1.24-2.33). CONCLUSION After controlling for patient, operative, and hernia characteristics, frailty was independently associated with increased odds of postoperative complications. These findings highlight the importance of preoperative frailty assessment for risk stratification and to inform patient counseling.
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Affiliation(s)
- Quintin P Solano
- University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Howard
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cody L Mullens
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne P Ehlers
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lia D Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Brian Fry
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Shen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
- Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, USA
| | - Dana Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA.
- Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, USA.
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Cox RM, Hendy BA, Gutman MJ, Sherman M, Abboud JA, Namdari S. Utilization of comorbidity indices to predict discharge destination and complications following total shoulder arthroplasty. Shoulder Elbow 2023; 15:274-282. [PMID: 37325391 PMCID: PMC10268142 DOI: 10.1177/17585732211049726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/11/2021] [Indexed: 09/20/2023]
Abstract
Background Comorbidity indices can help identify patients at risk for postoperative complications. Purpose of this study was to compare different comorbidity indices to predict discharge destination and complications after shoulder arthroplasty. Methods Retrospective review of institutional shoulder arthroplasty database of primary anatomic (TSA) and reverse (RSA) shoulder arthroplasties. Patient demographic information was collected in order to calculate Modified Frailty Index (mFI-5), Charlson Comorbidity Index (CCI), age adjusted CCI (age-CCI), and American Society of Anesthesiologists physical status classification system (ASA). Statistical analysis performed to analyze length of stay (LOS), discharge destination, and 90-day complications. Results There were 1365 patients included with 672 TSA and 693 RSA patients. RSA patients were older and had higher CCI, age adjusted CCI, ASA, and mFI-5 (p < 0.001). RSA patients had longer lengths of stay (LOS), more likely to have an adverse discharge (p < 0.001), and higher reoperation rate (p = 0.003). Age-CCI was most predictive of adverse discharge (AUC 0.721, 95% CI 0.704-0.768). Discussion Patients undergoing RSA had more medical comorbidities, experienced greater LOS, higher reoperation rate, and were more likely to have an adverse discharge. Age-CCI had the best ability to predict which patients were likely to require higher-level discharge planning.
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Affiliation(s)
- Ryan M. Cox
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin A. Hendy
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael J. Gutman
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Sherman
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A. Abboud
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Lewis LK, Jupiter DC, Panchbhavi VK, Chen J. Five-Factor Modified Frailty Index as a Predictor of Complications Following Total Ankle Arthroplasty. Foot Ankle Spec 2023:19386400231169368. [PMID: 37148165 DOI: 10.1177/19386400231169368] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Ankle arthritis adversely affects patients' function and quality of life. Treatment options for end-stage ankle arthritis include total ankle arthroplasty (TAA). A 5-item modified frailty index (mFI-5) has predicted adverse outcomes following multiple orthopaedic procedures; this study evaluated its suitability as a risk-stratification tool in patients undergoing TAA. METHODS The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for patients undergoing TAA between 2011 and 2017. Bivariate and multivariate statistical analyses were performed to investigate frailty as a possible predictor of postoperative complications. RESULTS In total, 1035 patients were identified. When comparing patients with an mFI-5 score of 0 versus ≥2, overall complication rates significantly increased from 5.24% to 19.38%, 30-day readmission rate increased from 0.24% to 3.1%, adverse discharge rate increased from 3.81% to 15.5%, and wound complications increased from 0.24% to 1.55%. After multivariate analysis, mFI-5 score remained significantly associated with patients' risk of developing any complication (P = .03) and 30-day readmission rate (P = .005). CONCLUSIONS Frailty is associated with adverse outcomes following TAA. The mFI-5 can help identify patients who are at an elevated risk of sustaining a complication, allowing for improved decision-making and perioperative care when considering TAA. LEVELS OF EVIDENCE III, Prognostic.
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Affiliation(s)
- Lauren K Lewis
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Daniel C Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch at Galveston, Galveston, Texas
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Vinod K Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch at Galveston, Galveston, Texas
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The Impact of Frailty Is Age Dependent in Patients Undergoing Primary Total Knee Arthroplasty: The Age-Adjusted Modified Frailty Index. J Arthroplasty 2023; 38:274-280. [PMID: 36064094 DOI: 10.1016/j.arth.2022.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Frailty is a well-established risk factor in patients undergoing total knee arthroplasty (TKA). How age modifies the impact of frailty on outcomes in these patients, however, remains unknown. In this study, we aimed to describe and evaluate the applicability of a novel risk stratification tool-the age-adjusted modified Frailty Index (aamFI)-in patients undergoing TKA. METHODS A national database was queried for all patients undergoing primary TKA from 2015 to 2019. There were 271,271 patients who met inclusion criteria for this study. First, outcomes were compared between chronologically young and old frail patients. In accordance with previous studies, the 75th percentile of age of all included patients (73 years) was used as a binary cutoff. Then, frailty was classified using the novel aamFI, which constitutes the 5-item mFI with the addition of 1 point for patients ≥73 years. Multivariable logistic regressions were then used to investigate the relationship between aamFI and postoperative outcomes. RESULTS Frail patients ≥73 years had a higher incidence of complications compared to frail patients <73 years. There was a strong association between aamFI and complications. An aamFI of ≥3 (reference aamFI of 0) was associated with an increased odds of 30-day mortality (odds ratio [OR] 8.6, 95% CI 5.0-14.8), any complication (OR 3.1, 95% CI 2.9-3.3), deep vein thrombosis (OR 1.5, 95% CI 1.2-1.8), and nonhome discharge (OR 6.1, 95% CI 5.8-6.4; all P < .001). CONCLUSION Although frailty negatively influences outcomes following TKA in patients of all ages, chronologically old, frail patients are particularly vulnerable. The aamFI accounts for this and represents a simple, but powerful tool for stratifying risk in patients undergoing primary TKA.
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Perioperative risk stratification tools for shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2023; 32:e293-e304. [PMID: 36621747 DOI: 10.1016/j.jse.2022.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/14/2022] [Accepted: 12/09/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Risk stratification tools are being increasingly utilized to guide patient selection for outpatient shoulder arthroplasty. The purpose of this study was to identify the existing calculators used to predict discharge disposition, postoperative complications, hospital readmissions, and patient candidacy for outpatient shoulder arthroplasty and to compare the specific components used to generate their prediction models. METHODS This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. PubMed, Cochrane Library, Scopus, and OVID Medline were searched for studies that developed calculators used to determine patient candidacy for outpatient surgery or predict discharge disposition, the risk of postoperative complications, and hospital readmissions after anatomic or reverse total shoulder arthroplasty (TSA). Reviews, case reports, letters to the editor, and studies including hemiarthroplasty cases were excluded. Data extracted included authors, year of publication, study design, patient population, sample size, input variables, comorbidities, method of validation, and intended purpose. The pros and cons of each calculator as reported by the respective authors were evaluated. RESULTS Eleven publications met inclusion criteria. Three tools assessed patient candidacy for outpatient TSA, 3 tools evaluated the risk of 30- or 90-day hospital readmission and postoperative complications, and 5 tools predicted discharge destination. Four calculators validated previously constructed comorbidity indices used as risk predictors after shoulder arthroplasty, including the Charlson Comorbidity Index, Elixhauser Comorbidity Index, modified Frailty Index, and the Outpatient Arthroplasty Risk Assessment, while 7 developed newcalculators. Nine studies utilized multiple logistic regression to develop their calculators, while 1 study developed their algorithm based on previous literature and 1 used univariate analysis. Five tools were built using data from a single institution, 2 using data pooled from 2 institutions, and 4 from large national databases. All studies used preoperative data points in their algorithms with one tool additionally using intraoperative data points. The number of inputs ranged from 5 to 57 items. Four calculators assessed psychological comorbidities, 3 included inputs for substance use, and 1 calculator accounted for race. CONCLUSION The variation in perioperative risk calculators after TSA highlights the need for standardization and external validation of the existing tools. As the use of outpatient shoulder arthroplasty increases, these calculators may become outdated or require revision. Incorporation of socioeconomic and psychological measures into these calculators should be investigated.
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22
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Shah NV, Kim DJ, Patel N, Beyer GA, Hollern DA, Wolfert AJ, Kim N, Suarez DE, Monessa D, Zhou PL, Eldib HM, Passias PG, Schwab FJ, Lafage V, Paulino CB, Diebo BG. The 5-factor modified frailty index (mFI-5) is predictive of 30-day postoperative complications and readmission in patients with adult spinal deformity (ASD). J Clin Neurosci 2022; 104:69-73. [PMID: 35981462 DOI: 10.1016/j.jocn.2022.07.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/19/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients. METHODS Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for > 7-level fusion or < 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes. RESULTS 2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were<20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for > 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p < 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome. CONCLUSION The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA.
| | - David J Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Neil Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - George A Beyer
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Douglas A Hollern
- Department of Orthopedic Surgery, USC Verdugo Hills Hospital, Los Angeles, CA, USA
| | - Adam J Wolfert
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Nathan Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Daniel E Suarez
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Dan Monessa
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Peter L Zhou
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Hassan M Eldib
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Carl B Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA; Department of Orthopaedic Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA; Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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23
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Seilern Und Aspang J, Zamanzadeh RS, Schwartz AM, Premkumar A, Martin JR, Wilson JM. The Age-Adjusted Modified Frailty Index: An Improved Risk Stratification Tool for Patients Undergoing Primary Total Hip Arthroplasty. J Arthroplasty 2022; 37:1098-1104. [PMID: 35189289 DOI: 10.1016/j.arth.2022.02.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Frailty and increasing age are well-established risk factors in patients undergoing total hip arthroplasty (THA). However, these variables have only been considered independently. This study assesses the interplay between age and frailty and introduces a novel age-adjusted modified frailty index (aamFI) for more refined risk stratification of THA patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2015 to 2019 for patients undergoing primary THA. First, outcomes were compared between chronologically younger and older frail patients. Then, to establish the aamFI, one additional point was added to the previously described mFI-5 for patients aged ≥73 years (the 75th percentile for age in our study population). The association of aamFI with postoperative complications and resource utilization was then analyzed categorically. RESULTS A total of 165,957 THA patients were evaluated. Older frail patients had a higher incidence of complications than younger frail patients. Regression analysis demonstrated a strong association between aamFI and complications. For instance, an aamFI of ≥3 (compared to aamFI of 0) was associated with an increased odds of mortality (OR: 22.01, 95% confidence interval [CI] 11.62-41.68), any complication (OR: 3.50, 95% CI 3.23-3.80), deep vein thrombosis (OR: 2.85, 95% CI 2.03-4.01), and nonhome discharge (OR 9.61, 95% CI 9.04-10.21; all P < .001). CONCLUSION Chronologically, older patients are impacted more by frailty than younger patients. The aamFI accounts for this and outperforms the mFI-5 in prediction of postoperative complications and resource utilization in patients undergoing primary THA.
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Affiliation(s)
| | - Ryan S Zamanzadeh
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - J Ryan Martin
- Department of Orthopaedics, Vanderbilt University, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Salzman GA, Saliba D, Ko CY, Maggard-Gibbons M, Russell MM. The Association of Frailty With Outcomes for Older Adults Undergoing Appendectomy. Am Surg 2022; 88:2456-2463. [PMID: 35576607 DOI: 10.1177/00031348221101493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Frailty is a potential modifiable predictor of surgical outcomes in older adults. The impact of frailty following appendectomy, a common urgent operation, is unknown for older adults. The study aim was to assess if frailty is associated with worse perioperative outcomes after appendectomy in older adults. METHODS We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2016 to 2018 and identified patients 65 and older who underwent appendectomy for acute appendicitis. We identified frailty as a Modified Frailty Index (MFI) score ≥2. Multivariate logistic regression was used to assess the association of frailty with 30-day mortality, serious complications, readmission, and discharge to facility. RESULTS Five thousand seven hundred twenty-eight older adults underwent appendectomy, of which 29.1% were 75 or older, 53.3% female, 74.9% non-Hispanic White, and 17.1% frail. Frail patients experienced worse outcomes: mortality (frail: 1.0% vs non-frail: .3%, P = .001), serious complications (14.2% vs 8.0%, P = <.0001), and discharge to facility (9.3% vs 2.3%, P < .0001). On multivariate logistic regression, frailty was associated with increased mortality (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.28-8.66), serious complications (OR 1.51; 95% CI: 1.17-1.93), and discharge to facility (OR 2.80; 95% CI: 2.00-3.93). Frailty was not significantly associated with readmission (P = .180). CONCLUSIONS Frailty is associated with worse postoperative outcomes following appendectomy in older adults. As frailty is potentially modifiable, it should be routinely assessed and utilized in perioperative optimization and counseling, especially with respect to patient-centered outcomes.
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Affiliation(s)
- Garrett A Salzman
- Department of Surgery, 12222University of California Los Angeles School of Medicine, Los Angeles, CA, USA.,Department of Surgery, 19975Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
| | - Debra Saliba
- Geriatrics Research, Education and Clinical Center, 19975Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA.,Borun Center, 12222University of California Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Clifford Y Ko
- Department of Surgery, 12222University of California Los Angeles School of Medicine, Los Angeles, CA, USA.,Department of Surgery, 19975Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
| | - Melinda Maggard-Gibbons
- Department of Surgery, 12222University of California Los Angeles School of Medicine, Los Angeles, CA, USA.,Department of Surgery, 19975Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
| | - Marcia M Russell
- Department of Surgery, 12222University of California Los Angeles School of Medicine, Los Angeles, CA, USA.,Department of Surgery, 19975Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA
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Le ST, Liu VX, Kipnis P, Zhang J, Peng PD, Cespedes Feliciano EM. Comparison of Electronic Frailty Metrics for Prediction of Adverse Outcomes of Abdominal Surgery. JAMA Surg 2022; 157:e220172. [PMID: 35293969 PMCID: PMC8928095 DOI: 10.1001/jamasurg.2022.0172] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Electronic frailty metrics have been developed for automated frailty assessment and include the Hospital Frailty Risk Score (HFRS), the Electronic Frailty Index (eFI), the 5-Factor Modified Frailty Index (mFI-5), and the Risk Analysis Index (RAI). Despite substantial differences in their construction, these 4 electronic frailty metrics have not been rigorously compared within a surgical population. Objective To characterize the associations between 4 electronic frailty metrics and to measure their predictive value for adverse surgical outcomes. Design, Setting, and Participants This retrospective cohort study used electronic health record data from patients who underwent abdominal surgery from January 1, 2010, to December 31, 2020, at 20 medical centers within Kaiser Permanente Northern California (KPNC). Participants included adults older than 50 years who underwent abdominal surgical procedures at KPNC from 2010 to 2020 that were sampled for reporting to the National Surgical Quality Improvement Program. Main Outcomes and Measures Pearson correlation coefficients between electronic frailty metrics and area under the receiver operating characteristic curve (AUROC) of univariate models and multivariate preoperative risk models for 30-day mortality, readmission, and morbidity, which was defined as a composite of mortality and major postoperative complications. Results Within the cohort of 37 186 patients, mean (SD) age, 67.9 (female, 19 127 [51.4%]), correlations between pairs of metrics ranged from 0.19 (95% CI, 0.18- 0.20) for mFI-5 and RAI 0.69 (95% CI, 0.68-0.70). Only 1085 of 37 186 (2.9%) were classified as frail based on all 4 metrics. In univariate models for morbidity, HFRS demonstrated higher predictive discrimination (AUROC, 0.71; 95% CI, 0.70-0.72) than eFI (AUROC, 0.64; 95% CI, 0.63-0.65), mFI-5 (AUROC, 0.58; 95% CI, 0.57-0.59), and RAI (AUROC, 0.57; 95% CI, 0.57-0.58). The predictive discrimination of multivariate models with age, sex, comorbidity burden, and procedure characteristics for all 3 adverse surgical outcomes improved by including HFRS into the models. Conclusions and Relevance In this cohort study, the 4 electronic frailty metrics demonstrated heterogeneous correlation and classified distinct groups of surgical patients as frail. However, HFRS demonstrated the highest predictive value for adverse surgical outcomes.
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Affiliation(s)
- Sidney T. Le
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
- The Permanente Medical Group, Oakland, California
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jie Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland
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26
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Simi AM, Chapman GC, Zillioux J, Martin S, Slopnick EA. Predictors of prolonged admission after outpatient female pelvic reconstructive surgery. Neurourol Urodyn 2022; 41:1031-1040. [PMID: 35347748 PMCID: PMC9314950 DOI: 10.1002/nau.24924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to determine factors associated with prolonged hospital admission following outpatient female pelvic reconstructive surgery (FPRS) and associated adverse clinical outcomes. METHODS Using the National Surgical Quality Improvement Program database, we identified outpatient FPRS performed 2011-2016. Isolated hysterectomy without concurrent prolapse repair was excluded. Surgeries were classified as major or minor for analysis. The primary outcome was prolonged length of stay (LOS), defined as admission of ≥2 days. Secondary outcomes included complications, readmission and reoperation associated with prolonged LOS. We abstracted data on covariates, and following univariable analysis, performed backward stepwise regression analysis. RESULTS A total of 29645 women were included: 12311 (41.5%) major and 17334 (58.5%) minor procedures. A total of 6.9% (2033) had a prolonged LOS. On full cohort multivariable regression analysis, patient characteristics associated with prolonged LOS were older age (odds ratio [OR]: 1.1 per 10 years, confidence interval [CI]: 1.06-1.1, p < 0.001), frailty (OR: 1.8, 95% CI: 1.3-2.6, p = 0.001), and Caucasian race (OR: 1.2, CI: 1.02-1.3, p = 0.024). Associated surgical factors included having a major surgical procedure (OR: 1.3, CI: 1.2-1.4, p < 0.001), use of general anesthesia (OR: 2.0, CI: 1.5-2.6, p < 0.001) and longer operative time (OR: 2.0, CI: 1.8-2.2, p < 0.001). The occurrence of any complication (10.3% vs. 4.7%, p < 0.001), hospital readmission (4.3% vs. 1.7%, p < 0.001), and reoperation (2.7% vs. 1.0%, p < 0.001) were more likely with prolonged LOS. CONCLUSIONS After outpatient FPRS, 6.9% of patients experience an admission of ≥2 days. Prolonged LOS is more common in patients who are older, frail and Caucasian, and in those who have major surgery with long operative time and general anesthesia.
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Affiliation(s)
- Andrea M. Simi
- Case Western Reserve University School of MedicineClevelandOhioUSA
| | - Graham C. Chapman
- Division of Urogynecology and Pelvic Floor Disorders, Department of Obstetrics and GynecologyCleveland Clinic FoundationClevelandOhioUSA
| | - Jacqueline Zillioux
- Department of Urology, Glickman Urological and Kidney InstituteCenter for Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic FoundationClevelandOhioUSA
| | - Sarah Martin
- Department of Urology, Glickman Urological and Kidney InstituteCenter for Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic FoundationClevelandOhioUSA
| | - Emily A. Slopnick
- Department of Urology, Glickman Urological and Kidney InstituteCenter for Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic FoundationClevelandOhioUSA
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27
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Lemos JL, Welch JM, Xiao M, Shapiro LM, Adeli E, Kamal RN. Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions. JBJS Rev 2021; 9:01874474-202112000-00006. [PMID: 34936580 DOI: 10.2106/jbjs.rvw.21.00065] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery. METHODS A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported. RESULTS The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome. CONCLUSIONS There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores. CLINICAL RELEVANCE Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.
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Affiliation(s)
- Jacie L Lemos
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Jessica M Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Michelle Xiao
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, California
| | - Ehsan Adeli
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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28
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Ravivarapu KT, Garden EB, Al-Alao O, Small AC, Palese MA. Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database. Am J Surg 2021; 223:1120-1125. [PMID: 34857360 DOI: 10.1016/j.amjsurg.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/22/2021] [Accepted: 11/15/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. METHODS All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). RESULTS 4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. CONCLUSIONS Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.
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Affiliation(s)
- Krishna T Ravivarapu
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan B Garden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Osama Al-Alao
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander C Small
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael A Palese
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Effects of preoperative nutritional status on complications and readmissions after posterior lumbar decompression and fusion for spondylolisthesis: A propensity-score analysis. Clin Neurol Neurosurg 2021; 211:107017. [PMID: 34781222 DOI: 10.1016/j.clineuro.2021.107017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Malnutrition, common in the elderly, may adversely affect healthcare outcomes. In spine surgery, malnutrition is associated with higher rates of perioperative complications, unplanned readmission, and prolonged length of stay (LOS). The aim of this study was to determine the effect of malnutrition on adverse events (AEs), unplanned readmission, and LOS in patients undergoing spine surgery for spondylolisthesis. METHODS A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2016. Adult patients who underwent posterior decompression or fusion for spondylolisthesis were identified using the ICD-9-CM coding systems. Patients were divided into two cohorts based on preoperative serum albumin levels. propensity-score (PS) matching was used to create an age- and sex-matched Nourished cohort. Patient demographics, comorbidities, LOS, and postoperative complications were collected. Multivariate logistic regression analysis was performed to identify predictors of prolonged LOS, unplanned readmission, and AEs. RESULTS Of the 2196 patients identified, 4.5% were malnourished. Patients in the Malnourished cohort were found to have significantly longer average LOS (Malnourished: 4.51 ± 3.1 days vs PS-Matched Not Nourished: 3.7 ± 3.7, p = 0.002), higher rates of AEs (Malnourished: 14.3% vs PS-Matched Nourished: 5.8%, p = 0.007), reoperation (Malnourished: 8.4% vs PS-Matched Nourished: 3.2%, p = 0.026), and unplanned readmission (Malnourished: 15.3% vs PS-Matched Nourished: 6.1%, p = 0.003). On multivariate analysis considering only preoperative data, malnutrition was a significant independent predictor of AEs [OR: 2.13, CI (1.02, 4.46), p = 0.045]. However, after correcting for the occurrence of AEs, malnutrition was not associated with total LOS [aRR: 0.29, CI (-0.37, 0.95), p = 0.392] or 30-day unplanned readmissions [aOR: 2.24, CI (0.89, 5.60), p = 0.086]. CONCLUSION Our study found that malnourished patients undergoing lumbar fusion for spondylolisthesis have significantly higher rates of AEs, unplanned readmission, and prolonged LOS than nourished patients. Further studies are necessary to corroborate our findings.
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Modified-frailty index does not independently predict complications, hospital length of stay or 30-day readmission rates following posterior lumbar decompression and fusion for spondylolisthesis. Spine J 2021; 21:1812-1821. [PMID: 34010683 DOI: 10.1016/j.spinee.2021.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Frailty has been associated with inferior surgical outcomes in various fields of spinal surgery. With increasing healthcare costs, hospital length of stay (LOS) and unplanned readmissions have emerged as clinical proxies reflecting overall value of care. However, there is a paucity of data assessing the impact that baseline frailty has on quality of care in patients with spondylolisthesis. PURPOSE The aim of this study was to investigate the impact that frailty has on LOS, complication rate, and unplanned readmission after posterior lumbar spinal fusion for spondylolisthesis. STUDY DESIGN A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. PATIENT SAMPLE All adult (≥18 years old) patients who underwent lumbar spinal decompression and fusion for spondylolisthesis were identified using ICD-9-CM diagnosis and procedural coding systems. We calculated the modified frailty index (mFI) for each patient using 5 dichotomous comorbidities - diabetes mellitus, congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, and dependent functional status. Each comorbidity is assigned 1 point and the points are summed to give a score between 0 and 5. As in previous literature, we defined a score of 0 as "not frail", 1 as "mild" frailty, and 2 or greater as "moderate to severe" frailty. OUTCOME MEASURES Patient demographics, comorbidities, complications, LOS, readmission, and reoperation were assessed. METHODS A multivariate logistic regression analysis was used to identify independent predictors of adverse events (AEs), extended LOS, complications, and unplanned readmission. RESULTS There were a total of 5,296 patients identified, of which 2,030 (38.3%) were mFI=0, 2,319 (43.8%) patients mFI=1, and 947 (17.9%) were mFI ≥2. The mFI≥2 cohort was older (p≤.001) and had a greater average BMI (p≤.001). The mFI≥2 cohort had a slightly longer hospital stay (3.7 ± 2.3 days vs. mFI=1: 3.5 ± 2.8 days and mFI=0: 3.2 ± 2.1 days,p≤.001). Both surgical AEs and medical AEs were significantly greater in the mFI≥2 cohort than the other cohorts, (2.6% vs. mFI=1: 1.8% and mFI=0: 1.2%,p=.022) and (6.3% vs. mFI=1: 4.8% and mFI=0: 2.6%,p≤.001), respectively. While there was no significant difference in reoperation rates, the mFI≥2 cohort had greater unplanned 30-day readmission rates (8;4% vs. mFI=5.6: 4.8% and mFI=0: 3.4%,p≤.001). However, on multivariate regression analysis, mFI≥2 was not a significant independent predictor of LOS (p=.285), complications (p=.667), or 30-day unplanned readmission (p=.378). CONCLUSIONS Our study indicates that frailty, as measured by the mFI, does not significantly predict LOS, 30-day adverse events, or 30-day unplanned readmission in patients undergoing lumbar spinal decompression and fusion for spondylolisthesis. Further work is needed to better define variable inputs that make up frailty to optimize surgical outcome prediction tools that impact the value of care.
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Roopsawang I, Zaslavsky O, Thompson H, Aree-Ue S, Kwan RYC, Belza B. Frailty measurements in hospitalised orthopaedic populations age 65 and older: A scoping review. J Clin Nurs 2021; 31:1149-1163. [PMID: 34622525 PMCID: PMC9293223 DOI: 10.1111/jocn.16035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Abstract
Aims and Objectives To identify and compare frailty instruments used with hospitalised orthopaedic patients aged over 65. Background Frailty predicts clinical events in orthopaedic patients aged over 65. However, the strengths and limitations of different approaches to measuring frailty in this population are rarely discussed. As such, a comprehensive review to address the gap is needed. Design Scoping review using Arksey and O’Malley framework. Methods PubMed, CINAHL, PsycINFO, Scopus and EMBASE databases were searched to identify studies published from 2006 to 2020 regarding frailty instruments in older orthopaedic patients. The Preferred Reporting Items for Systematic Reviews and Meta‐analyses were followed. Results The initial search resulted in 1,471 articles. After review against inclusion and exclusion criteria, a final set of 31 articles containing 15 unique frailty instruments were evaluated. Most of the articles were from Western countries. Fried's phenotype and Frailty Index were commonly used. The frailty index was mostly modified to measure frailty. In hip fracture, physical function items were frequently modified in the measurement of frailty. Trained physicians and nurses administered most frailty instruments. Frailty screening was commonly conducted at hospital admission and used to prognosticate both postoperative complications and hospital outcomes. Most instruments could be completed within 10 min. Reported psychometrics had acceptable reliability and validity. Conclusion Many reliable frailty measures have been used in the inpatient orthopaedic settings; however, evidence is still lacking for a gold standard frailty instrument. More research is needed to identify the best‐performing measure. Frailty evaluation in patients with physical limitations is challenging with existing instruments. Clinical context, resources required and instrument quality are essential factors in selecting a frailty instrument. Relevance to clinical practice Musculoskeletal symptoms in older patients may bias frailty assessment. Proactive frailty screening with valid and practical instruments is vital to strengthen preoperative risk stratification and improve post‐surgical outcomes.
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Affiliation(s)
- Inthira Roopsawang
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oleg Zaslavsky
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
| | - Hilaire Thompson
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
| | - Suparb Aree-Ue
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rick Yiu Cho Kwan
- Centre for Gerontological Nursing, School of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | - Basia Belza
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
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Pelvic Organ Prolapse Surgery in the Elderly and Frail: Safety of a Reconstructive Versus Obliterative Approach. Female Pelvic Med Reconstr Surg 2021; 27:e620-e625. [PMID: 34432731 DOI: 10.1097/spv.0000000000001029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to compare the risk of complications associated with obliterative surgery versus reconstructive surgery in elderly and frail patients undergoing surgery for pelvic organ prolapse. METHODS We performed a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2017. We compared characteristics and perioperative complications in patients aged 80 years or older who underwent obliterative surgery versus reconstructive surgery. Multivariate logistic regression and propensity score matching were used to control for confounding. A subanalysis was performed that included patients who were considered frail as defined by the National Surgical Quality Improvement Program Modified Frailty Index 5. RESULTS Of 1,654 total patients, reconstructive surgery was performed in 56.9% of patients, and obliterative surgery was performed in 43.1%. The respective composite complication rates were 9.2% and 9.8% (P = 0.69), whereas severe complications were experienced by 1.9% in the reconstructive group versus 0.8% in the obliterative group (P = 0.07). On multivariate logistic regression, reconstructive surgery was not significantly associated with the composite complication rate (adjusted odds ratio, 1.0; 95% confidence interval, 0.7-1.4; P = 0.80). After propensity score matching, composite complications did not differ between groups, but the rate of severe complications was significantly higher in patients who underwent reconstructive surgery compared with obliterative surgery (2.1% vs 0.8%; odds ratio, 2.53; 95% confidence interval, 1.01-6.36; P = 0.05). In frail patients only, complication rates did not differ between groups. CONCLUSIONS In patients aged 80 years or older, the overall rate of complications did not differ between those who underwent reconstructive surgery versus obliterative surgery. However, propensity score matching identified an increased risk of the most severe complications in patients who underwent reconstructive surgery.
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Moorthy V, Lee M, Ang BFH, Chen JY, Lie DTT. Comparing the Predictors of Functional Outcomes After Arthroscopic Rotator Cuff Repair Modified Frailty Index, Clinical Frailty Scale, and Charlson Comorbidity Index. Orthop J Sports Med 2021; 9:23259671211005091. [PMID: 34350299 PMCID: PMC8287367 DOI: 10.1177/23259671211005091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/25/2021] [Indexed: 12/21/2022] Open
Abstract
Background: The incidence of rotator cuff tears increases with age, and operative
management is usually required in patients with persistent symptoms.
Although several studies have analyzed the effect of age and comorbidities
on outcomes after rotator cuff repair, no study has specifically examined
the consequence of frailty. Purpose: To determine the best frailty/comorbidity index for predicting functional
outcomes after arthroscopic rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: The authors conducted a retrospective cohort study of 340 consecutive
patients who underwent unilateral arthroscopic rotator cuff repair at a
tertiary hospital between April 2016 and April 2018. All patients had
undergone arthroscopic double-row rotator cuff repair with subacromial
decompression by a single fellowship-trained shoulder surgeon. Patient
frailty was measured using the Modified Frailty Index (MFI), Clinical
Frailty Scale (CFS), and Charlson Comorbidity Index (CCI), calculated
through retrospective chart review based on case notes made just before
surgery; patient age and sex were also noted preoperatively. Functional
outcomes using the Oxford Shoulder Score (OSS), Constant Shoulder Score
(CSS), University of California Los Angeles (UCLA) Shoulder Score, and
visual analog scale for pain were measured preoperatively and at 3, 6, 12,
and 24 months postoperatively. Results: The MFI was a consistent significant predictor in all functional outcome
scores up to 24 months postoperatively (P < .05), unlike
the CFS and CCI. Sex was also a significant predictor of postoperative OSS,
CSS, and UCLA Shoulder Score, with male sex being associated with better
functional outcomes. Patients with higher MFI scores had slower functional
improvement postoperatively, but they eventually attained functional outcome
scores comparable with those of their counterparts with lower MFI scores at
24 months postoperatively. Conclusion: The MFI was found to be a better tool for predicting postoperative function
than was the CFS or CCI in patients undergoing arthroscopic rotator cuff
repair. The study findings suggest that a multidimensional assessment of
frailty (including both functional status and comorbidities) is important in
determining functional outcomes after arthroscopic rotator cuff repair.
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Affiliation(s)
- Vikaesh Moorthy
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Merrill Lee
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Farley KX, Wilson JM, Kumar A, Gottschalk MB, Daly C, Sanchez-Sotelo J, Wagner ER. Prevalence of Shoulder Arthroplasty in the United States and the Increasing Burden of Revision Shoulder Arthroplasty. JB JS Open Access 2021; 6:JBJSOA-D-20-00156. [PMID: 34278185 PMCID: PMC8280071 DOI: 10.2106/jbjs.oa.20.00156] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Existing data on the epidemiology of shoulder arthroplasty are limited to future projections of incidence. However, the prevalence of shoulder arthroplasty (the number of individuals with a shoulder arthroplasty alive at a certain time and its implications for the burden of revision procedures) remains undetermined for the United States. Hence, the purpose of this study was to estimate the prevalence of shoulder arthroplasty in the United States.
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Affiliation(s)
- Kevin X Farley
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Anjali Kumar
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | | | - Charles Daly
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | | | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
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Hermiz SJR, Lauzon S, Brown G, Herrera FA. Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction. Ann Plast Surg 2021; 86:S615-S621. [PMID: 33625028 DOI: 10.1097/sap.0000000000002765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction. METHODS The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded. RESULTS A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related. CONCLUSION Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.
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Affiliation(s)
| | | | - Geoffrey Brown
- College of Medicine, Medical University of South Carolina, Charleston, SC
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Alkadri J, Hage D, Nickerson LH, Scott LR, Shaw JF, Aucoin SD, McIsaac DI. A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data. Anesth Analg 2021; 133:1094-1106. [PMID: 33999880 DOI: 10.1213/ane.0000000000005595] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment. METHODS Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed. RESULTS Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported. CONCLUSIONS Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.
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Affiliation(s)
- Jamal Alkadri
- From the Department of Anesthesiology & Pain Medicine
| | - Dima Hage
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lia R Scott
- Department of General Surgery, Queen's University, Ottawa, Ontario, Canada
| | - Julia F Shaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Daniel I McIsaac
- From the Department of Anesthesiology & Pain Medicine.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Schultz MA, Walden RL, Cato K, Coviak CP, Cruz C, D'Agostino F, Douthit BJ, Forbes T, Gao G, Lee MA, Lekan D, Wieben A, Jeffery AD. Data Science Methods for Nursing-Relevant Patient Outcomes and Clinical Processes: The 2019 Literature Year in Review. Comput Inform Nurs 2021; 39:654-667. [PMID: 34747890 PMCID: PMC8578863 DOI: 10.1097/cin.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Data science continues to be recognized and used within healthcare due to the increased availability of large data sets and advanced analytics. It can be challenging for nurse leaders to remain apprised of this rapidly changing landscape. In this article, we describe our findings from a scoping literature review of papers published in 2019 that use data science to explore, explain, and/or predict 15 phenomena of interest to nurses. Fourteen of the 15 phenomena were associated with at least one paper published in 2019. We identified the use of many contemporary data science methods (eg, natural language processing, neural networks) for many of the outcomes. We found many studies exploring Readmissions and Pressure Injuries. The topics of Artificial Intelligence/Machine Learning Acceptance, Burnout, Patient Safety, and Unit Culture were poorly represented. We hope that the studies described in this article help readers: (1) understand the breadth and depth of data science's ability to improve clinical processes and patient outcomes that are relevant to nurses and (2) identify gaps in the literature that are in need of exploration.
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Affiliation(s)
- Mary Anne Schultz
- Author Affiliations: California State University (Dr Schultz); Annette and Irwin Eskind Family Biomedical Library, Vanderbilt University (Ms Walden); Department of Emergency Medicine, Columbia University School of Nursing (Dr Cato); Grand Valley State University (Dr Coviak); Global Health Technology & Informatics, Chevron, San Ramon, CA (Mr Cruz); Saint Camillus International University of Health Sciences, Rome, Italy (Dr D'Agostino); Duke University School of Nursing (Mr Douthit); East Carolina University College of Nursing (Dr Forbes); St Catherine University Department of Nursing (Dr Gao); Texas Woman's University College of Nursing (Dr Lee); Assistant Professor, University of North Carolina at Greensboro School of Nursing (Dr Lekan); University of Wisconsin School of Nursing (Ms Wieben); and Vanderbilt University School of Nursing, and Tennessee Valley Healthcare System, US Department of Veterans Affairs (Dr Jeffery)
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Wilson JM, Farley KX, Gottschalk MB, Daly CA, Wagner ER. Preoperative opioid use is an independent risk factor for complication, revision, and increased health care utilization following primary total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:1025-1033. [PMID: 32853788 DOI: 10.1016/j.jse.2020.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/26/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. METHODS The Truven Marketscan claims database was used to identify patients who underwent primary, unilateral TSA. Preoperative opioid use status was then used to divide patients into cohorts based on the average daily oral morphine equivalents (OMEs) received in the 6-month preoperative period. This included the following cohorts: opioid naïve and <1, 1-5, 5-10, and >10 average daily OMEs. In total, 29,454 patients with 90-day postoperative follow-up were included. Of these, 21,580 patients and 8959 patients had 1- and 3-year follow-up, respectively. Patient information and complication data were collected. Univariate and multivariate logistic regression were then performed to assess the association of preoperative opioid use with postoperative outcomes. A subgroup analysis was performed to examine revision surgery at 1 and 3 years postoperatively. RESULTS Forty-four percent of identified patients received preoperative opioids, but the preoperative opioid-naïve patient became more common over the study period. Multivariate analysis demonstrated that patients receiving >10 average daily OMEs (compared with opioid naïve) had higher odds of opioid overdose (odds ratio [OR] 4.17, 95% confidence interval [CI] 1.57-11.08, P = .004), wound complication (OR 2.04, 95% CI 1.44-2.89, P < .001), superficial surgical site infection (OR 2.33, 95% CI 1.63-3.34, P < .001), prosthetic joint infection (OR 3.41, 95% CI 2.50-4.67, P < .001), pneumonia (OR 1.95, 95% CI 1.39-2.75, P < .001), and thromboembolic event (OR 1.42, 95% CI 1.18-1.72, P < .001). The same group had higher health care utilization, including extended length of stay, nonhome discharge, readmission, and emergency department visits (P ≤ .001). Total perioperative adjusted costs were more than $7000 higher in the >10-OME group when compared to preoperative opioid-naïve patients. DISCUSSION Opioid use prior to TSA is common and is associated with increased complications, health care utilization, revision surgery, and costs. This risk is dose dependent, and efforts should be made at cessation prior to surgery.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kevin X Farley
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael B Gottschalk
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles A Daly
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric R Wagner
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA.
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Impact of Frailty and Malnutrition on Outcomes After Surgical Fixation of Lower Extremity Fractures in Young Patients. J Orthop Trauma 2021; 35:e126-e133. [PMID: 32910628 DOI: 10.1097/bot.0000000000001952] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Evaluate the relationship of nutrition parameters and the modified frailty index (mFI) on postsurgical complications within a young patient population sustaining lower extremity orthopaedic trauma. DESIGN Retrospective observational cohort study. SETTING Urban, American College of Surgeons-Verified, Level-1, Trauma Center. PATIENTS/PARTICIPANTS Seventeen-thousand one hundred nine adult patients under the age of 65 sustaining lower extremity fractures undergoing operative intervention from 2006 to 2018. MAIN OUTCOME MEASURES On admission, mFI and albumin levels were obtained, as well as complication data. Statistical analysis was used to analyze the association between frailty, malnutrition, and postoperative complications. Patients were stratified, healthy (mFI ≤1, albumin ≥3.5 g/dL), malnourished (mFI ≤1, albumin <3.5 g/dL), frail (mFI ≥2, albumin ≥3.5 g/dL), and frail and malnourished (mFI ≥2, albumin <3.5 g/dL). RESULTS 60.4% of patients were healthy, 18.8% were malnourished, 11.7% were frail, and 9.0% were frail and malnourished. Frailty and/or malnourishment on admission predicted significantly higher odds of postoperative complications and mortality when compared with healthy patients. Frailty and malnourishment in conjunction predicted a significantly higher odds ratio of 1.46 (1.22-1.75) for developing postoperative complications when compared with the only malnourished. This was also observed when compared with the only frail (odd ratio: 1.61, P < 0.001); however, there was also a 2.72 (P < 0.001) increased odds of mortality. CONCLUSIONS Frailty and malnutrition in conjunction predicts a subset of patients with a higher risk of postoperative complications beyond that of frailty or malnutrition in isolation. Identification of these physiological states on admission allows for interventional opportunities during hospitalization. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Dammeyer K, Alfonso AR, Diep GK, Kantar RS, Berman ZP, Daar DA, Ramly EP, Sosin M, Ceradini DJ. Predicting postoperative complications following mastectomy in the elderly: Evidence for the 5-factor frailty index. Breast J 2021; 27:509-513. [PMID: 33650221 DOI: 10.1111/tbj.14208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/11/2021] [Accepted: 02/10/2021] [Indexed: 01/01/2023]
Abstract
Understanding the risk factors that contribute to post-mastectomy complications can better inform preoperative discussions. Here, we assess the impact of the 5-Factor Frailty Index Score (mFI-5) in predicting 30-day postoperative complications in patients undergoing mastectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data base was conducted for patients older than 65 undergoing mastectomy between 2010 and 2015. We assessed each patient's Frailty Index Score using the mFI-5. Primary outcomes included wound complications and overall complications. Multivariate logistic and linear regression analyses were used to determine the ability of the mFI-5 to predict postoperative outcomes. A total of 13,783 patients were analyzed. The rate of wound complications was 3.0%, while the rate of overall complications was 6.0%. An mFI-5 score greater than 2 was an independent risk factor for wound complications and overall complications. Overall, patients undergoing mastectomy with an mFI-5 of 2 or greater experienced higher rates of postoperative complications. The mFI-5 is an accessible tool that can be used to risk-stratify patients undergoing mastectomy and can positively contribute to the informed consent and shared decision-making process.
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Affiliation(s)
- Kristen Dammeyer
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Gustave K Diep
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Zoe P Berman
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - David A Daar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Michael Sosin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York, USA
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Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis. Int Urogynecol J 2021; 32:1391-1398. [PMID: 33638678 DOI: 10.1007/s00192-021-04673-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly. METHODS The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications. RESULTS A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications. CONCLUSION ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.
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Zupo R, Castellana F, Bortone I, Griseta C, Sardone R, Lampignano L, Lozupone M, Solfrizzi V, Castellana M, Giannelli G, De Pergola G, Boeing H, Panza F. Nutritional domains in frailty tools: Working towards an operational definition of nutritional frailty. Ageing Res Rev 2020; 64:101148. [PMID: 32827687 DOI: 10.1016/j.arr.2020.101148] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 12/11/2022]
Abstract
Different methods have been proposed for the assessment of the nutritional status in frailty phenotypes. In the present narrative review article, we have summarized the number and specifications of nutritional items in existing frailty tools, in order to develop a possible means of assessment and operational definition of the nutritional frailty phenotype. In six different databases until December 2019, we searched for original articles regarding frailty tools (i.e., scales, indexes, scores, questionnaires, instruments, evaluations, screening, indicators), analyzing each tool regarding nutritional items. We identified 160 articles describing 71 frailty tools. Among the selected frailty tools, 54 were community-based (70 %), 17 hospital-based (22 %), 4 validated in long-term care institutions for older adults (LTCIOA) (5.1 %) and 2 validated in both community- and hospital-based settings, including LTCIOA (2.5 %). Fifty-two of these tools (73 %) included at least one nutritional item. Twenty-two (42 %) reported two or more nutritional items. The items were grouped in the following categories: A) anthropometric measurements, B) laboratory measurements, and C) other nutritional-related measurements. Anthropometric measurements stood out compared to all other items. Nutritional items are included in the majority of frailty tools, strengthening the concept that they may have a direct implication on an increased risk of adverse health-related outcomes in frail subjects. This supports the development of the concept of nutritional frailty as an independent frailty phenotype. Subsequent steps will be to assess the contribution of each nutritional item to a possible operational definition of nutritional frailty and define the items that may best identify this new frailty phenotype.
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The 5 and 11 Factor Modified Frailty Indices are Equally Effective at Outcome Prediction Using TQIP. J Surg Res 2020; 255:456-462. [DOI: 10.1016/j.jss.2020.05.090] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/07/2020] [Accepted: 05/24/2020] [Indexed: 12/21/2022]
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Schwartz AM, Wilson JM, Farley KX, Bradbury TL, Guild GN. Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty. J Arthroplasty 2020; 35:2878-2885. [PMID: 32576431 DOI: 10.1016/j.arth.2020.05.062] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) demand continues to rise, but we are also gaining greater insight into patient risk factors for postoperative complications and excess resource utilization. There has been growing interest in frailty and malnutrition as risk factors, although they are often mistakenly used interchangeably. We aimed at identifying the incidence of their coexistence, and the magnitude of risk they confer to TKA patients. METHODS We queried the American College of Surgeons-National Surgery Quality Improvement Program database to identify 4 patient cohorts: healthy/normal serum albumin, healthy/hypoalbuminemic patients, normoalbuminemic/medically frail patients (defined by modified frailty index), and hypoalbuminemic/frail patients. We performed both univariate and multivariate analyses to quantify the risk conferred by each condition in isolation, and in coexistence. RESULTS Of 179,702 elective TKA cases from 2006 to 2018, 18.6% of patients were frail only, 3.0% were hypoalbuminemic -only, and just 1.2% were both frail and hypoalbuminemic. The raw rate of any complication was highest in frail/hypoalbuminemic patients (8.7%), 5.2% in hypoalbuminemic patients, 4.8% in frail patients, and just 3.4% in healthy patients (P < .001); the multivariate model revealed odds ratio of a complication in frail/hypoalbuminemic group of 2.40 (95% confidence interval = 1.27-1.63; P < .001). Mortality within 30 days was highest in the frail/hypoalbuminemic cohort (1.0%), and just 0.1% in healthy patients, and the multivariate model noted an odds ratio of 9.43 for these patients (95% confidence interval = 5.92-14.93; P < .001). The odds of all studied complications were highest in the frail/hypoalbuminemic group. CONCLUSION Frailty and hypoalbuminemia represent distinct conditions and are independent risk factors for a complication after TKA. Their coexistence imparts a synergistic association with the risk of post-TKA complications.
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Wilson JM, Schwartz AM, Farley KX, Bradbury TL, Guild GN. Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty. J Arthroplasty 2020; 35:2488-2494. [PMID: 32444236 DOI: 10.1016/j.arth.2020.04.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/06/2020] [Accepted: 04/10/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient. METHODS This is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts. RESULTS 105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001). CONCLUSIONS Frailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.
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Perioperative Safety of Surgery for Pelvic Organ Prolapse in Elderly and Frail Patients. Obstet Gynecol 2020; 135:599-608. [PMID: 32028502 DOI: 10.1097/aog.0000000000003682] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of old age and frailty on complication rates after surgery for pelvic organ prolapse. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for prolapse from 2010 to 2017. We compared our control group (45-64 years, index population) to those aged 65-79 years (elderly) and 80 years and older (very elderly). Frailty was assessed using the National Surgical Quality Improvement Program Modified Frailty Index-5. The primary outcome was the composite rate of serious complications and mortality. RESULTS We analyzed 27,403 patients in the index population, 20,567 in the elderly group, and 3,088 in the very elderly group. The composite rate of serious complications in the index population was 4.5%, compared with 4.7% in the elderly group (odds ratio [OR] 1.0, 95% CI 0.9-1.1) and 9.0% in the very elderly group (OR 2.1, 95% CI 1.8-2.4). Compared with the index group, the very elderly group had notably elevated risks of cardiac complications (OR 11.9, 95% CI 6.2-23.0), stroke (OR 26.6, 95% CI 5.4-131.8), and mortality (OR 39.9, 95% CI 8.6-184.7). On multivariate logistic regression, the only age group independently associated with serious complications was the very elderly group (adjusted odds ratio [aOR] 2.01, 95% CI 1.8-2.3). The Modified Frailty Index-5 score was independently predictive of complications (aOR 1.4, 95% CI 1.1-2.0). Stratified analysis using interaction terms revealed the Modified Frailty Index-5 score to be predictive of complications in the elderly age group (aOR 2.5, 95% CI 1.3-4.6), but not in the very elderly group. CONCLUSION Serious complications surrounding prolapse surgery increase substantially in the cohort of patients older than 80 years of age, independent of frailty and medical or surgical risk factors.
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Modified Frailty Index Predicts Postoperative Complications following Panniculectomy in the Elderly. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2987. [PMID: 32802676 PMCID: PMC7413797 DOI: 10.1097/gox.0000000000002987] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/26/2020] [Indexed: 11/27/2022]
Abstract
Due to the high complication rate of panniculectomies, preoperative risk stratification is imperative. This study aimed to assess the predictive value of the 5-item modified frailty index (mFI-5) for postoperative complications in the elderly following panniculectomy.
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Amer KM, Congiusta DV, Suri P, Merchant AM, Vosbikian MM, Ahmed IH. Patient frailty as a risk assessment tool in surgical management of long bone fractures. J Clin Orthop Trauma 2020; 11:S591-S595. [PMID: 32774034 PMCID: PMC7394786 DOI: 10.1016/j.jcot.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/06/2020] [Accepted: 01/19/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Frailty is an important predictor of surgical outcomes and has been quantified by several models. The modified frailty index (mFI) has recently been adapted from an 11-item index to a 5-item index and has promise to be a valuable risk assessment tool in orthopedic trauma patients. We perform a retrospective analysis of the 5-item mFI and evaluate its effectiveness in predicting outcomes in patients with long bone fractures. METHODS The National Surgery Quality Improvement Program (NSQIP) 2006-2016 database was queried for surgical procedures in the treatment of long bone fractures by current procedural terminology (CPT) codes, excluding those performed on metacarpals and metatarsals. Cases were excluded if they were missing demographic, frailty, and variable data. The 5-item frailty index was calculated based on the sum of presence of 5 conditions: COPD/pneumonia, congestive heart failure, diabetes, hypertension, and impaired functional status. Chi square was used to determine variables significantly associated with each outcome. The significant variables were included in multivariate logistic regression along with the mFI. Significance was defined as p < 0.05. RESULTS Of the 140,249 fixation procedures performed on long bone fractures in NSQIP, 109,423 cases remained after exclusion criteria were applied. The majority of patients were between the ages of 61 and 80 (34.0%), were female (65.6%) and Caucasian (86.3%). Multivariate analysis revealed that mFI scores ≥3 were predictive of unplanned reoperation (OR = 1.57), wound disruption (OR = 2.83), unplanned readmission (OR = 2.12), surgical site infection (OR = 1.90), major complications (OR = 3.04), and discharge destination (OR = 3.06). CONCLUSIONS Our study analyzed the relationship of frailty and postoperative complications in patients with long bone fractures. Patients had increased likelihood of morbidity, independent of other comorbidities and demographic factors. The mFI may have a role as a simple, easy to use risk assessment tool in cases of orthopedic trauma.
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Affiliation(s)
| | | | - Pooja Suri
- Corresponding author. Rutgers New Jersey Medical School, Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, United States.
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Poh AWY, Teo SP. Utility of Frailty Screening Tools in Older Surgical Patients. Ann Geriatr Med Res 2020; 24:75-82. [PMID: 32743327 PMCID: PMC7370792 DOI: 10.4235/agmr.20.0023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 12/17/2022] Open
Abstract
Frailty is a loss of functional reserve that compromises a person's ability to cope with stressors such as surgery. Identifying and quantifying frailty may enable intensive rehabilitation interventions, caregiver support, or consideration of palliative care before surgery. This study describes the characteristics of five frailty screening tools, namely the Geriatric 8, Vulnerable Elders Survey-13, the Groningen Frailty Indicator, Edmonton Frailty Scale (EFS), and Clinical Frailty Scale. We further propose an approach incorporating a frailty scale into preoperative assessment, wherein older patients undergoing elective general surgery are screened using EFS, and frail patients are offered comprehensive geriatric assessment. The expected outcome is an individualized patient-centered care plan that will reduce frailty and optimize the patient's condition before surgery.
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Affiliation(s)
- Alicia Wan Yan Poh
- Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam
| | - Shyh Poh Teo
- Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam
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Gowd AK, Agarwalla A, Amin NH, Romeo AA, Nicholson GP, Verma NN, Liu JN. Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:e410-e421. [PMID: 31383411 DOI: 10.1016/j.jse.2019.05.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND We aimed to demonstrate that supervised machine learning (ML) models can better predict postoperative complications after total shoulder arthroplasty (TSA) than comorbidity indices. METHODS The American College of Surgeons-National Surgical Quality Improvement Program database was queried from 2005-2017 for TSA cases. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, extended length of stay (>3 days), surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, and readmission. Each SML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and the positive predictive value (PPV) of complications. RESULTS We identified a total of 17,119 TSA cases. Mean age, BMI, and length of stay were 69.5 ± 9.6 years, 31.1 ± 6.8, and 2.0 ± 2.2 days. Percentage hematocrit, BMI, and operative time were of highest importance in outcome prediction. SML algorithms outperformed ASA classification models for predicting any adverse event (71.0% vs. 63.0%), transfusion (77.0% vs. 64.0%), extended length of stay (68.0% vs. 60.0%), surgical site infection (65.0% vs. 58.0%), return to the operating room (59.0% vs. 54.0%), and readmission (64.0% vs. 58.0%). SML algorithms demonstrated the greatest PPV for any adverse event (62.5%), extended length of stay (61.4%), transfusion (52.2%), and readmission (10.1%). ASA classification had a 0.0% PPV for complications. CONCLUSION With continued validation, intelligent models could calculate patient-specific risk for complications to adjust perioperative care and site of surgery.
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Affiliation(s)
- Anirudh K Gowd
- Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
| | | | - Nirav H Amin
- Veterans Affairs Loma Linda, Loma Linda, CA, USA
| | | | | | | | - Joseph N Liu
- Loma Linda University Medical Center, Loma Linda, CA, USA
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