Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool within a Multi-practice, Multi-hospital Integrated Healthcare System

The Surgical Pause: The Importance of Measuring Frailty and Taking Action to Address Identified Frailty

CONCEPTUAL FRAMEWORK

The Surgical Pause is a rapid, scalable strategy for health care systems to optimize perioperative outcomes for high-risk, frail patients considering elective surgery. The first and most important step is to screen for frailty, thereby identifying the 5% to 10% of patients at most risk for postoperative complications, loss of independence, institutionalization, and mortality. The second step is to take action to improve outcomes. Action may include clarifying perioperative goals, optimizing perioperative decision-making, and mitigating frailty-associated risks through prehabilitation.

HISTORY OF DISSEMINATION

Initially implemented at the Omaha Veterans Affairs (VA) Medical Center in 2012, the Surgical Pause was associated with a nearly three-fold survival advantage among the frail. The program was subsequently replicated at more than 50 VA and private sector hospitals with similarly robust results, leading the Veterans Health Administration (VHA) National Surgery Office to formally adopt the program in January 2024. The Joint Commission and the National Quality Forum recognized the program with the Eisenberg Award for Patient Safety and Quality at the National Level.

LESSONS LEARNED

Successful dissemination grew from simultaneous real-world quality projects paralleled by rigorous, high-quality, peer reviewed publications demonstrating the need for and impact of the Surgical Pause. Adoption was facilitated in an iterative process to streamline feasibility and leverage existing resources. Success was accelerated by national infrastructure catalyzing a community of practice.

CONCLUSION

The Surgical Pause is changing surgical culture by proactively identifying frail patients, aligning treatment plans with patient-defined goals, optimizing perioperative decisions, and mitigating frailty-associated risks to deliver both quality and value.

Frailty Screening Using the Risk Analysis Index: A User Guide

The Risk Analysis Index (RAI) has emerged as the most thoroughly validated and flexible assessment of surgical frailty, proven feasible for at-scale bedside screening and available in a suite of tools, that effectively risk stratifies patients across a wide variety of clinical contexts and data sources. This user guide provides a definitive summary of the RAI's theoretical model, historical development, validation, statistical performance, and clinical interpretation, placing the RAI in context with other frailty assessments and emphasizing some of its advantages. Detailed instructions are provided for each RAI variant, along with a systematic review of existing RAI-related literature.

The impact of frailty on patient selection and outcomes for open versus endovascular treatment of unruptured intracranial aneurysms: A propensity-score matched analysis

BACKGROUND AND OBJECTIVES

Endovascular treatment (EVT) has been demonstrated to have improved post-operative outcomes and fewer complications compared to open microsurgical clipping of unruptured intracranial aneurysms (UIAs). Our study analyzes patient selection and outcomes for open versus EVT stratified by frailty measured using the Risk Analysis Index (RAI).

METHODS

This was a retrospective study of patients who underwent open or EVT for an UIA at our institution between March 2017 and June 2022. Propensity-score matching (PSM) was performed using the 1:1 nearest neighbour method to create two groups (open and EVT) matched by demographics and treatment modality. RAI-measured frailty was used to categorize patients into 4 tiers: robust (0-10), pre-frail (11-20), frail (21-30) and severely frail (≥31). Outcomes of interest were length of stay (LOS), functional dependence at discharge and 30-day readmission.

RESULTS

After PSM, 209 patients were stratified into two groups, open and EVT, respectively. Patients who received EVT were older compared to open surgery (mean ± SD: 62.6 ± 11.4 vs. 60.8 ± 10.6, P < 0.05), however, RAI-measured frailty did not differ significantly between the two groups (median (IQR) open: 3 (2-7), vs. EVT: 3 (2-9)), P = 0.090. Among robust and pre-frail patients, EVT was associated with significantly shorter LOS compared to open surgery, median (IQR): 1 (1-2) vs. 3 (2-4) and 1 (1-2), vs. 3 (2-6); P < 0.001, respectively). Neither functional dependence at discharge nor 30-day readmission rates were different after stratification by frailty.

CONCLUSION

Patients in the robust and pre-frail tiers experienced significantly shorter LOS after EVT compared to open surgery. We would like to encourage the use of frailty assessment as a pre-operative risk stratification tool patients undergoing treatment of UIAs.

Association Between Frailty and Preoperative Decision-Making in Rectal Prolapse Repair

INTRODUCTION

Abdominal and perineal repairs for rectal prolapse are offered to patients based on surgeon assessment of risk. Interpretations of risk can vary. We sought to understand how the preoperative Risk Analysis Index (RAI) score, a validated measure of frailty, aligned with our existing decision-making process for rectal prolapse repair.

METHODS

Rectal prolapse repair cases were recorded in an Institutional Review Board approved registry from 2017 to 2022. Abdominal and perineal operations were determined based on an experienced surgeon's recommendation. The preoperative RAI was collected; a score≥30 indicates significant frailty. Preoperative and postoperative characteristics were compared using t-tests and Fisher's exact tests.

RESULTS

About 130 patients underwent abdominal repairs and 51 underwent perineal repairs. Perineal patients were more often frail (abdominal: 9 [7%] versus perineal: 21 [41%], P < 0.001) and had a higher rate of cardiac comorbidities (abdominal: 42 [32%] versus perineal: 35 [69%], P < 0.001). A similar share of patients were undergoing repair for recurrent prolapse (abdominal: n = 29 [22%] versus perineal: n = 11 [22%], P > 0.99). Perineal repair patients were more likely to need assistance with mobility (n = 24 [47%]) and live in a facility (n = 15 [29%]). Patients in both groups recovered well (complication rate abdominal: 28 [22%] versus 11 [22%], P > 0.99) and were satisfied with postoperative outcomes (Patient Global Impression of Change score abdominal: 6 [interquartile range: 6, 7] versus perineal: 6 [5, 7], P = 0.12). Recurrence rates were higher after perineal repair (abdominal: 12 [9%] versus perineal: 20 [39%], P < 0.001).

CONCLUSIONS

Most abdominal repair patients were not frail, but many nonfrail patients underwent perineal operations based on surgeon perception of comorbidities. Using the RAI tool may provide an opportunity to guide decision-making around operative approach for rectal prolapse and overcome potential surgeon bias.

Risk Analysis Index Frailty Score as a Predictor of Otolaryngology Surgical Outcomes

OBJECTIVE

The Risk Analysis Index (RAI) score is a screening tool to assess patient frailty. It has been shown to be predictive of postoperative outcomes and mortality in orthopedic, urologic, and neurosurgical patient populations. We sought to evaluate the predictive ability of RAI score for surgical outcomes in an otolaryngology patient population.

STUDY DESIGN

Retrospective study.

SETTING

Academic tertiary medical center.

METHODS

A retrospective study was conducted of adult patients undergoing otolaryngology surgery at a tertiary medical care center over 21 months. Patients were sent electronic RAI survey questionnaires via direct messaging, which was completed prior to surgery. Endpoint data were analyzed, including demographics, RAI score, and patient outcome data. Univariate analysis, ROC curves, and predictive modeling were utilized.

RESULTS

A total of 517 patients responded to the RAI questionnaire, resulting in a 59.6% response rate. Mean RAI score was 21.38 ± 11.83. Higher RAI scores were associated with increased 30-day readmissions (P < .0015), postoperative complications (P < .001), hospital length of stay (P < .001), and discharge with home health (P < .001). Predictive models for RAI score and postoperative outcomes were created, and a cutoff score of RAI = 30 was established to identify frail patients.

CONCLUSION

We evaluated if RAI scoring predicted postoperative complications in an otolaryngology patient population. Increased RAI score is significantly associated with poorer surgical outcomes, including increased hospital length of stay, 30-day readmissions, and postoperative complications. We propose a predictive model with suggested RAI cutoff scoring for use in the otolaryngology surgical population.

Comparison of a Risk Calculator With Frailty Indices in Patients Undergoing Lung Cancer Resection

INTRODUCTION

While frailty has gained attention for its utility in risk stratification, no studies have directly compared them to existing risk calculators. The objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other than home.

METHODS

Patients undergoing anatomic lung resection for primary, nonsmall cell lung cancer were identified within the ACS National Quality Improvement Program (ACS NSQIP) database. Tools were compared for discrimination in the primary outcomes.

RESULTS

9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (IQR 59-74) years. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% CI). This included perioperative mortality (AUC 0.74, 95% CI 0.71-0.78), compared to RAI-rev (AUC 0.66, 95% CI 0.62-0.69) and 5-mFI (AUC 0.61, 95% CI 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes.

CONCLUSION

ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

Comparison of a risk calculator with frailty indices in patients undergoing lung cancer resection

INTRODUCTION

Perioperative risk stratification is an essential component of preoperative planning for cancer surgery. While frailty has gained attention for its utility in risk stratification, no studies have directly compared it to existing risk calculators. Therefore, the objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other-than-home.

METHODS

Patients undergoing anatomic lung resection for primary, non-small cell lung cancer were identified within the American College of Surgeons National Quality Improvement Program (ACS NSQIP) database. The ACS-SRC, RAI-rev, and 5-mFI tools were used to predict adverse postoperative events. Tools were compared for discrimination in the primary outcomes.

RESULTS

9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (interquartile range = 59-74) years. Cardiothoracic surgeons performed 89% and general surgeons performed 11.0% of the operations. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% confidence interval [CI]). This included perioperative mortality (AUC = 0.74, 95% CI = 0.71-0.78), compared to RAI-rev (AUC = 0.66, 95% CI = 0.62-0.69) and 5-mFI (AUC = 0.61, 95% CI = 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes.

CONCLUSION

ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

Frailty Predicts 30-day mortality following major complications in neurosurgery patients: The risk analysis index has superior discrimination compared to modified frailty index-5 and increasing patient age

Background

Postoperative complications after cranial or spine surgery are prevalent, and frailty can be a key contributing patient factor. Therefore, we evaluated frailty's impact on 30-day mortality. We compared the discrimination for risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for predicting 30-day mortality.

Methods

Patients with major complications following neurosurgery procedures between 2012- 2020 in the ACS-NSQIP database were included. We employed receiver operating characteristic (ROC) curve and examined discrimination thresholds for RAI, mFI-5, and increasing patient age for 30-day mortality. Independent relationships were examined using multivariable analysis.

Results

There were 19,096 patients included in the study and in the ROC analysis for 30-day mortality, RAI showed superior discriminant validity threshold C-statistic 0.655 (95% CI: 0.644-0.666), compared to mFI-5 C-statistic 0.570 (95% CI 0.559-0.581), and increasing patient age C-statistic 0.607 (95% CI 0.595-0.619). When the patient population was divided into subsets based on the procedures type (spinal, cranial or other), spine procedures had the highest discriminant validity threshold for RAI (Cstatistic 0.717). Furthermore, there was a frailty risk tier dose response relationship with 30-day mortalityy (p<0.001).

Conclusion

When a major complication arises after neurosurgical procedures, frail patients have a higher likelihood of dying within 30 days than their non-frail counterparts. The RAI demonstrated a higher discriminant validity threshold than mFI-5 and increasing patient age, making it a more clinically relevant tool for identifying and stratifying patients by frailty risk tiers. These findings highlight the importance of initiatives geared toward optimizing frail patients, to mitigate long-term disability.

Decision making in the frail vascular surgery patient: A scoping review

Increasing evidence highlights the adverse impact of frailty and reduced physiologic reserve on surgical outcomes. Therefore, identification of frailty is essential for older adults being evaluated for vascular surgery procedures. Numerous frailty assessment tools are available to quantify the level of frailty and assist in preoperative decision making for these older patients. This review evaluates traditional and novel frailty metrics for their scientific validation, limitations, and clinical utility in vascular surgery decision-making.

Trajectory Analysis of Health Care Utilization Before and After Major Surgery

OBJECTIVE

To characterize patterns of health care utilization before and after surgery and determine any association with preoperative frailty.

BACKGROUND

Frail patients experience worse postoperative outcomes and increased costs during the surgical encounter. Evidence is comparatively lacking for the longer-term effects of frailty on postoperative health care utilization.

METHODS

Retrospective, longitudinal cohort analysis of adult patients undergoing any elective surgical procedure after preoperative frailty assessment with the Risk Analysis Index from February 2016 to December 2020 at a large integrated health care delivery and financing system. Group-based trajectory modeling of claims data estimated distinct clusters of patients with discrete utilization trajectories. Multivariable regression predicted membership in trajectories of interest using preoperative characteristics, including frailty.

RESULTS

Among 29,067 surgical encounters, 4 distinct utilization trajectories emerged in longitudinal data from the 12 months before and after surgery. All cases exhibited a surge in utilization during the surgical month, after which most patients returned to "low" [25,473 (87.6%)], "medium" [1403 (4.8%)], or "high" [528 (1.8%)] baseline utilization states established before surgery. The fourth trajectory identified 1663 (5.7%) cases where surgery occasioned a transition from "low" utilization before surgery to "high" utilization afterward. Risk Analysis Index score alone did not effectively predict membership in this transition group, but a multivariable model with other preoperative variables was effective ( c = 0.859, max rescaled R2 = 0.264).

CONCLUSIONS

Surgery occasions the transition from low to high health care utilization for a substantial subgroup of surgical patients. Multivariable modeling may effectively discriminate this utilization trajectory, suggesting an opportunity to tailor care processes for these patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODOLOGY/PRINCIPAL FINDINGS

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

CONCLUSIONS/SIGNIFICANCE

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

Adaptation of the Risk Analysis Index for Frailty Assessment Using Diagnostic Codes

Importance

Frailty is associated with adverse outcomes after even minor physiologic stressors. The validated Risk Analysis Index (RAI) quantifies frailty; however, existing methods limit application to in-person interview (clinical RAI) and quality improvement datasets (administrative RAI).

Objective

To expand the utility of the RAI utility to available International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) administrative data, using the National Inpatient Sample (NIS).

Design, Setting, and Participants

RAI parameters were systematically adapted to ICD-10-CM codes (RAI-ICD) and were derived (NIS 2019) and validated (NIS 2020). The primary analysis included survey-weighed discharge data among adults undergoing major surgical procedures. Additional external validation occurred by including all operative and nonoperative hospitalizations in the NIS (2020) and in a multihospital health care system (UPMC, 2021-2022). Data analysis was conducted from January to May 2023.

Exposures

RAI parameters and in-hospital mortality.

Main Outcomes and Measures

The association of RAI parameters with in-hospital mortality was calculated and weighted using logistic regression, generating an integerized RAI-ICD score. After initial validation, thresholds defining categories of frailty were selected by a full complement of test statistics. Rates of elective admission, length of stay, hospital charges, and in-hospital mortality were compared across frailty categories. C statistics estimated model discrimination.

Results

RAI-ICD parameters were weighted in the 9 548 206 patients who were hospitalized (mean [SE] age, 55.4 (0.1) years; 3 742 330 male [weighted percentage, 39.2%] and 5 804 431 female [weighted percentage, 60.8%]), modeling in-hospital mortality (2.1%; 95% CI, 2.1%-2.2%) with excellent derivation discrimination (C statistic, 0.810; 95% CI, 0.808-0.813). The 11 RAI-ICD parameters were adapted to 323 ICD-10-CM codes. The operative validation population of 8 113 950 patients (mean [SE] age, 54.4 (0.1) years; 3 148 273 male [weighted percentage, 38.8%] and 4 965 737 female [weighted percentage, 61.2%]; in-hospital mortality, 2.5% [95% CI, 2.4%-2.5%]) mirrored the derivation population. In validation, the weighted and integerized RAI-ICD yielded good to excellent discrimination in the NIS operative sample (C statistic, 0.784; 95% CI, 0.782-0.786), NIS operative and nonoperative sample (C statistic, 0.778; 95% CI, 0.777-0.779), and the UPMC operative and nonoperative sample (C statistic, 0.860; 95% CI, 0.857-0.862). Thresholds defining robust (RAI-ICD <27), normal (RAI-ICD, 27-35), frail (RAI-ICD, 36-45), and very frail (RAI-ICD >45) strata of frailty maximized precision (F1 = 0.33) and sensitivity and specificity (Matthews correlation coefficient = 0.26). Adverse outcomes increased with increasing frailty.

Conclusion and Relevance

In this cohort study of hospitalized adults, the RAI-ICD was rigorously adapted, derived, and validated. These findings suggest that the RAI-ICD can extend the quantification of frailty to inpatient adult ICD-10-CM-coded patient care datasets.

Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings

Importance

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking.

Objective

To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.

Design, Setting, and Participants

This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.

Exposures

Surgical care in VA or private-sector hospitals.

Main Outcomes and Measures

Postoperative 30-day mortality and failure to rescue (FTR).

Results

Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.

Conclusions and Relevance

Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

Impact of Frailty on Postoperative Outcomes in Extended Endonasal Skull Base Surgery for Suprasellar Pathologies

OBJECTIVE

Frailty metrics estimate a patient's ability to tolerate physiologic stress and there are limited frailty data in patients undergoing expanded endonasal approaches (EEA) for suprasellar pathologies. Elevated frailty metrics have been associated with increased perioperative complications in patients undergoing craniotomies. We sought to examine this potential relationship in EEA.

STUDY DESIGN

Retrospective cohort study.

SETTING

Two tertiary academic skull base centers.

METHODS

Cases of patients undergoing EEA for suprasellar pathologies were reviewed. Demographic, treatment, survival, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, the modified 5-item frailty index (mFI-5), and the Charlson comorbidity index (CCI). Primary outcomes included 30-day medical and surgical complications.

RESULTS

A total of 88 patients were included, with 59 (67%) female patients and a mean age of 54 ± 15 years. The most common pathologies included 53 meningiomas (60.2%) and 21 craniopharyngiomas (23.9%). Most patients were ASA class 3 (54.5%) with mean mFI-5 0.82 ± 1.01 and CCI 4.18 ± 2.42. There was no association between increased frailty and 30-day medical or surgical outcomes (including postoperative cerebrospinal fluid leak), prolonged length of hospital stay, or mortality (all P > .05). Higher mFI-5 was associated with an increased risk for 30-day readmission (odds ratio: 2.35, 95% confidence Interval: 1.10-5.64, P = .04).

CONCLUSION

Despite the patient population being notably frail, we only identified an increased risk for 30-day readmission and observed no links with deteriorating surgical, medical, or mortality outcomes. This implies that conventional frailty metrics may not effectively align with EEA outcomes.

The risk analysis index demonstrates superior discriminative ability in predicting extended length of stay in pituitary adenoma resection patients when compared to the 5-point modified frailty index

Objective

To compare the predictive abilities of two frailty indices on post-operative morbidity and mortality in patients undergoing pituitary adenoma resection.

Methods

The National Surgical Quality Improvement Program (NSQIP) database was used to retrospectively collect data for patients undergoing pituitary adenoma resection between 2015-2019. To compare the predictive abilities of two of the most common frailty indices, the 5-point modified frailty index (mFI-5) and the risk analysis index (RAI), receiver operating curve analysis (ROC) and area under the curve (AUC)/Cstatistic were used.

Results

In our cohort of 1,454 patients, the RAI demonstrated superior discriminative ability to the mFI-5 in predicting extended length of stay (C-statistic 0.59, 95% CI 0.56-0.62 vs. C-statistic 0.51, 95% CI: 0.48-0.54, p = 0.0002). The RAI only descriptively appeared superior to mFI-5 in determining mortality (C-statistic 0.89, 95% CI 0.74-0.99 vs. Cstatistic 0.63, 95% CI 0.61-0.66, p=0.11), and NHD (C-statistic 0.68, 95% CI 0.60-0.76 vs. C-statistic 0.60, 95% CI: 0.57-0.62, p=0.15).

Conclusions

Pituitary adenomas account for one of the most common brain tumors in the general population, with resection being the preferred treatment for patients with most hormone producing tumors or those causing compressive symptoms. Although pituitary adenoma resection is generally safe, patients who experience post-operative complications frequently share similar pre-operative characteristics and comorbidities. Therefore, appropriate pre-operative risk stratification is imperative for adequate patient counseling and informed consent in these patients. Here we present the first known report showing the superior discriminatory ability of the RAI in predicting eLOS when compared to the mFI-5.

A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty

INTRODUCTION

The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers.

METHODS

We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality.

RESULTS

Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality.

CONCLUSIONS

While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

Impact of Frailty on Patient Outcomes after Hartmann's Reversal: A NSQIP Analysis

BACKGROUND

Colostomy reversal is a common procedure. Patients often have baseline comorbidities associated with postoperative morbidity. We utilized a modified frailty index (mFI-5) to predict postoperative complications.

METHODS

Patients who underwent elective, open Hartmann's reversal were queried from the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified to low, medium, or high frailty groups. Statistical analysis was performed using chi-squared, ANOVA, and logistic regression.

RESULTS

There were 9272 patients with Hartmann's reversal. 48.78%, 30.31%, and 12.89% had low, moderate, or high frailty, respectively. High frailty was associated with cardiac arrest, myocardial infarction, reintubation, prolonged intubation, early reoperation, and mortality. After multivariate analysis, high frailty was associated with prolonged intubation (OR 3.147, P = .001), reintubation (OR 2.548, P = .002), and reoperation (OR 1.67, P < .001).

CONCLUSIONS

Frailty was associated with greater risk of postoperative complications in patients undergoing Hartmann's reversal. Frailty may be a useful adjunct to stratify for patients who are at risk for postoperative complications.

Automated Electronic Frailty Index-Identified Frailty Status and Associated Postsurgical Adverse Events

Importance

Electronic frailty index (eFI) is an automated electronic health record (EHR)-based tool that uses a combination of clinical encounters, diagnosis codes, laboratory workups, medications, and Medicare annual wellness visit data as markers of frailty status. The association of eFI with postanesthesia adverse outcomes has not been evaluated.

Objective

To examine the association of frailty, calculated as eFI at the time of the surgical procedure and categorized as fit, prefrail, or frail, with adverse events after elective noncardiac surgery.

Design, Setting, and Participants

This cohort study was conducted at a tertiary care academic medical center in Winston-Salem, North Carolina. The cohort included patients 55 years or older who underwent noncardiac surgery of at least 1 hour in duration between October 1, 2017, and June 30, 2021.

Exposure

Frailty calculated by the eFI tool. Preoperative eFI scores were calculated based on available data 1 day prior to the procedure and categorized as fit (eFI score: ≤0.10), prefrail (eFI score: >0.10 to ≤0.21), or frail (eFI score: >0.21).

Main Outcomes and Measures

The primary outcome was a composite of the following 8 adverse component events: 90-item Patient Safety Indicators (PSI 90) score, hospital-acquired conditions, in-hospital mortality, 30-day mortality, 30-day readmission, 30-day emergency department visit after surgery, transfer to a skilled nursing facility after surgery, or unexpected intensive care unit admission after surgery. Secondary outcomes were each of the component events of the composite.

Results

Of the 33 449 patients (median [IQR] age, 67 [61-74] years; 17 618 females [52.7%]) included, 11 563 (34.6%) were classified as fit, 15 928 (47.6%) as prefrail, and 5958 (17.8%) as frail. Using logistic regression models that were adjusted for age, sex, race and ethnicity, and comorbidity burden, patients with prefrail (odds ratio [OR], 1.24; 95% CI, 1.18-1.30; P < .001) and frail (OR, 1.71; 95% CI, 1.58-1.82; P < .001) statuses were more likely to experience postoperative adverse events compared with patients with a fit status. Subsequent adjustment for all other potential confounders or covariates did not alter this association. For every increase in eFI of 0.03 units, the odds of a composite of postoperative adverse events increased by 1.06 (95% CI, 1.03-1.13; P < .001).

Conclusions and Relevance

This cohort study found that frailty, as measured by an automatically calculated index integrated within the EHR, was associated with increased risk of adverse events after noncardiac surgery. Deployment of eFI tools may support screening and possible risk modification, especially in patients who undergo high-risk surgery.

Frailty does not worsen postoperative outcomes in sinonasal squamous cell carcinoma

PURPOSE

Sinonasal squamous cell carcinoma (SCC) is an aggressive malignancy frequently requiring surgical resection and adjuvant treatment. Frailty is a metric that attempts to estimate a patient's ability to tolerate the physiologic stress of treatment. There is limited work describing frailty in patients with sinonasal cancer. We sought to determine the impact of frailty on postoperative outcomes in patients undergoing treatment for sinonasal SCC.

MATERIALS AND METHODS

Cases of patients undergoing surgical resection of sinonasal SCC at two tertiary medical centers were queried. Demographic, treatment, and survival data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, modified 5-item frailty index (mFI-5), and the Charlson Comorbidity Index (CCI). Primary outcomes included medical and surgical complications, readmission, and length of stay (LOS).

RESULTS

38 patients were included. There were 23 (60.5 %) men and 15 (39.5 %) women with an average age of 59.6 ± 12.1 years. MFI-5 was 0.76 ± 0.54 and CCI was 5.71 ± 2.64. No significant association was noted between frailty measures and postoperative outcomes including 30-day medical complications, 30-day surgical complications, any 30-day complication, and readmission. Increased ASA was noted to be predictive of increased length of stay (Incidence Rate Ratio: 1.80, 95 % confidence interval [CI]: 1.16-2.83, p = 0.009).

CONCLUSIONS

We found no association between frailty metrics and worsening surgical or medical postoperative outcomes. This suggests that frailty metrics may not be as relevant for sinonasal surgery even for advanced pathologies, given the more limited physiologic impact of minimally invasive surgery.

Frailty Indexes in Metastatic Spine Tumor Surgery: A Narrative Review

Quantification of preoperative frailty is an important prognostic tool in neurosurgical decision making. Metastatic spine tumor patients undergoing surgery are frail and have unfavorable outcomes that include an increased length of stay, unfavorable discharge disposition, and increased readmission rates. These undesirable outcomes result in higher treatment costs. A heterogeneous mixture of various frailty indexes is available with marked variance in their validation, leading to disparate clinical utility. The lack of a universally accepted definition for frailty, let alone in the method of creation or elements required in the formation of a frailty index, has resulted in a body of frailty literature lacking precision for predicting neurosurgical outcomes. In this review, we examine the role of reported frailty indexes in predicting postoperative outcomes after resection of metastatic spine tumors and aim to assist as a frailty guide for helping clinical decision making.

Frailty in aneurysmal subarachnoid hemorrhage: the risk analysis index

BACKGROUND

Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research.

METHODS

Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2.

RESULTS

42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001).

CONCLUSION

The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors.

Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer

Importance

Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment.

Objective

To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC.

Design, Setting, and Participants

In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded.

Exposures

Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS).

Main Outcome(s) and Measure(s)

The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL).

Results

Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (β, 2.96; 95% CI, 0.29-5.62).

Conclusions and Relevance

Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.

Preoperative frailty and adverse outcomes following coronary artery bypass grafting surgery in US veterans

BACKGROUND

Contemporary guidelines emphasize the value of incorporating frailty into clinical decision-making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer-term mortality among coronary artery bypass grafting (CABG) patients.

METHODS

We conducted a retrospective cohort study (2016-2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA-FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non-frail (VA-FI ≤ 0.1), pre-frail (0.1 < VA-FI ≤ 0.2), or frail (VA-FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all-cause mortality. Our primary study outcome was 5-year all-cause mortality; the co-primary outcome was days alive and out of the hospital within the first postoperative year.

RESULTS

There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre-operative VA-FI was 0.21 (SD: 0.11); 31% were pre-frail (VA-FI: 0.17) and 47% were frail (VA-FI: 0.31). Frail patients were older and had higher co-morbidity burdens than pre-frail and non-frail patients. Compared with non-frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre-frail patients and increased cumulative 5-year all-cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre-frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non-frail patients (mean 362[SD 12]), pre-frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year.

CONCLUSIONS

Pre-frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid-term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery.

The Risk Analysis Index Has Superior Discrimination Compared With the Modified Frailty Index-5 in Predicting Worse Postoperative Outcomes for the Octogenarian Neurosurgical Patient

BACKGROUND AND IMPORTANCE

Healthcare systems continuously strive to improve quality and value of care. Advances in surgical technologies, enhanced perioperative surgical planning, and multidisciplinary care strategies are increasing the number of elective procedures in the geriatric population. However, frail older adults are still more likely to have poor postoperative outcomes. We examined the impact of frailty on postoperative outcomes, we compared the discriminative thresholds for the Risk Analysis Index (RAI), modified Frailty Index-5 (mFI-5), and increasing patient age.

CLINICAL PRESENTATION

Octogenarian patients undergoing spine, cranial, and other procedures captured in the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2020 were included. We used receiver operating characteristic curve to examine discriminative thresholds of RAI, mFI-5, and increasing patient age. Multivariable analyses were performed. Our primary outcomes were 30-day mortality, extended length of stay (eLOS [≥75th percentile]), and continued inpatient care >30 days (pLOS). Secondary outcomes were skilled care facility (skilled nursing facility [SNF]) discharges and readmissions.

DISCUSSION

In total, 20 710 octogenarians were included, with a mean age of 83 years (SD, 2.5) and a men (52.7%) and White (79.8%) majority. The RAI had higher predictive discriminative thresholds for 30-day mortality (C-statistic of 0.743), eLOS (C-statistic: 0.692), and pLOS (C-statistic: 0.697) compared with the mFI-5 (C-statistic: 0.574, 0.556, and 0.550, respectively), and increasing patient age (C-statistic: 0.577, 0.546, and 0.504, respectively), P < .001. On multivariable analyses, RAI showed a larger effect size with adverse postoperative outcomes by increasing frailty strata than mFI-5 and increasing patient age. Nonetheless RAI showed decreased risk for SNF discharges.

CONCLUSION

We found that RAI was a more accurate predictor than mFI-5 and increasing patient age for 30-day mortality, eLOS, and pLOS in octogenarian neurosurgery patients. More research is needed on RAI's performance in different specialized neurosurgical populations. Moreover, it is increasingly clear that comprehensive risk assessment strategies tailored to optimize perioperative care should be prioritized to potentially improve outcomes for this at-risk population.

Value-Based Care and Anesthesiology in the USA

Value-based care, prioritizing patient outcomes over service volume, is steering a transformative course in anesthesiology in the United States. With the rise of this patient-centric approach, anesthesiologists are adopting dynamic roles to meet the demands of medical institutions, insurers, and patients for high-quality, cost-effective care. The urgency for this transition is accentuated by persistent challenges in reducing postoperative mortality rates and surgical complications, further spotlighted by the coronvirus disease 2019 (COVID-19) pandemic. Anesthesiologists engage in preoperative optimization, personalized care delivery, and evidence-based practices, bolstering their influence in the perioperative environment. Their collaboration with perioperative stakeholders propels the shift toward a value-driven healthcare landscape. This review analyzes the implementation of value-based care in American anesthesiology, assesses the significance of technology in enhancing its delivery, and outlines potential strategies for improving its application.

Longitudinal Analysis of Caregiver Burden in Head and Neck Cancer

Importance

Despite the critical role of caregivers in head and neck cancer (HNC), there is limited literature on caregiver burden (CGB) and its evolution over treatment. Research is needed to address evidence gaps that exist in understanding the causal pathways between caregiving and treatment outcomes.

Objective

To evaluate the prevalence of and identify risk factors for CGB in HNC survivorship.

Design, Setting, and Participants

This longitudinal prospective cohort study took place at the University of Pittsburgh Medical Center. Dyads of treatment-naive patients with HNC and their caregivers were recruited between October 2019 and December 2020. Eligible patient-caregiver dyads were 18 years or older and fluent in English. Patients undergoing definitive treatment identified a caregiver as the primary, nonprofessional, nonpaid person who provided the most assistance to them. Among 100 eligible dyadic participants, 2 caregivers declined participation, resulting in 96 enrolled participants. Data were analyzed from September 2021 through October 2022.

Main Outcomes and Measures

Participants were surveyed at diagnosis, 3 months postdiagnosis, and 6 months postdiagnosis. Caregiver burden was evaluated with the 19-item Social Support Survey (scored 0-100, with higher scores indicating more support), Caregiver Reaction Assessment (CRA; scored 0-5, with higher scores on 4 subscales [disrupted schedule, financial problems, lack of family support, and health problems] indicating negative reactions, and higher scores on the fifth subscale [self-esteem] indicating favorable influence); and 3-item Loneliness Scale (scored 3-9, with higher scores indicating greater loneliness). Patient health-related quality of life was assessed using the University of Washington Quality of Life scale (UW-QOL; scored 0-100, with higher scores indicating better QOL).

Results

Of the 96 enrolled participants, half were women (48 [50%]), and a majority were White (92 [96%]), married or living with a partner (81 [84%]), and working (51 [53%]). Of these participants, 60 (63%) completed surveys at diagnosis and at least 1 follow-up. Of the 30 caregivers, most were women (24 [80%]), White (29 [97%]), married or living with a partner (28 [93%]), and working (22 [73%]). Caregivers of nonworking patients reported higher scores on the CRA subscale for health problems than caregivers of working patients (mean difference, 0.41; 95% CI, 0.18-0.64). Caregivers of patients with UW-QOL social/emotional (S/E) subscale scores of 62 or lower at diagnosis reported increased scores on the CRA subscale for health problems (UW-QOL-S/E score of 22: CRA score mean difference, 1.12; 95% CI, 0.48-1.77; UW-QOL-S/E score of 42: CRA score mean difference, 0.74; 95% CI, 0.34-1.15; and UW-QOL-S/E score of 62: CRA score mean difference, 0.36; 95% CI, 0.14-0.59). Woman caregivers had statistically significant worsening scores on the Social Support Survey (mean difference, -9.18; 95% CI, -17.14 to -1.22). The proportion of lonely caregivers increased over treatment.

Conclusions and Relevance

This cohort study highlights patient- and caregiver-specific factors that are associated with increased CGB. Results further demonstrate the potential implications for negative health outcomes for caregivers of patients who are not working and have lower health-related quality of life.

Prospective application of the risk analysis index to measure preoperative frailty in spinal tumor surgery: A single center outcomes analysis

Introduction

Surgeons are frequently faced with challenging clinical dilemmas evaluating whether the benefits of surgery outweigh the substantial risks routinely encountered with spinal tumor surgery. The Clinical Risk Analysis Index (RAI-C) is a robust frailty tool administered via a patient-friendly questionnaire that strives to augment preoperative risk stratification. The objective of the study was to prospectively measure frailty with RAI-C and track postoperative outcomes after spinal tumor surgery.

Methods

Patients surgically treated for spinal tumors were followed prospectively from 7/2020-7/2022 at a single tertiary center. RAI-C was ascertained during preoperative visits and verified by the provider. The RAI-C scores were assessed in relation to postoperative functional status (measured by modified Rankin Scale score [mRS]) at the last follow-up visit.

Results

Of 39 patients, 47% were robust (RAI 0-20), 26% normal (21-30), 16% frail (31-40), and 11% severely frail (RAI 41+).). Pathology included primary (59%) and metastatic (41%) tumors with corresponding mRS>2 rates of 17% and 38%, respectively. Tumors were classified as extradural (49%), intradural extramedullary (46%), or intradural intramedullary (5.4%) with mRS>2 rates of 28%, 24%, and 50%, respectively. RAI-C had a positive association with mRS>2 ​at follow-up: 16% for robust, 20% for normal, 43% for frail, and 67% for severely frail. The two deaths in the series had the highest RAI-C scores (45 and 46) and were patients with metastatic cancer. The RAI-C was a robust and diagnostically accurate predictor of mRS>2 in receiver operating characteristic curve analysis (C-statistic: 0.70, 95 CI: 0.49-0.90).

Conclusions

The findings exemplify the clinical utility of RAI-C frailty scoring for prediction of outcomes after spinal tumor surgery and it has potential to help in the surgical decision-making process as well as surgical consent. As a preliminary case series, the authors intend to provide additional data with a larger sample size and longer follow-up duration in a future study.

A toolbox for a structured risk-based prehabilitation program in major surgical oncology

Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.

Operative Management of Thyroid Disease in Older Adults

As the population ages, both domestically and globally, clinicians will increasingly find themselves navigating treatment decisions for thyroid disease in older adults. When considering surgical treatment, individualizing risk assessment is particularly important, as older patients can present with very different health profiles. While fit, independent individuals may benefit from thyroidectomy with minimal risk, those with multiple comorbidities and poor functional status are at higher risk of perioperative complications, which can have adverse health effects and detract from long-term quality of life. In order to optimize surgical outcomes for older adults, strategies for accurate risk assessment and mitigation are being explored. Surgical decision-making also should consider the characteristics of the thyroid disease being treated, given many benign thyroid disorders and some well-differentiated thyroid cancers can be appropriately managed nonoperatively without compromising longevity. Shared decision-making becomes increasingly important to respect the health priorities and optimize outcomes for older adults with thyroid disease. This review summarizes the current knowledge of thyroid surgery in older adults to help inform decision-making among patients and their physicians.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Interpreting the risk analysis index of frailty in the context of surgical oncology

BACKGROUND AND OBJECTIVES

The Risk Analysis Index (RAI) accurately predicts adverse postoperative outcomes but the inclusion of cancer status in the RAI has raised two key concerns about its suitability for use in surgical oncology: (1) the potential over classification of cancer patients as frail, and (2) the potential overestimation of postoperative mortality for patients with surgically curable cancers.

METHODS

We performed a retrospective cohort analysis to assess the RAI's power to appropriately identify frailty and predict postoperative mortality in cancer patients. We assessed discrimination for mortality and calibration across five RAI models-the complete RAI and four variants that removed different cancer-related variables.

RESULTS

We found that the presence of disseminated cancer was a key variable driving the RAI's power to predict postoperative mortality. The model including only this variable [RAI (disseminated cancer)] was similar to the complete RAI in the overall sample (c = 0.842 vs. 0.840) and outperformed the complete RAI in the cancer subgroup (c = 0.736 vs 0.704, respectively, p < 0.0001, Max R2  = 19.3% vs. 15.1%, respectively).

CONCLUSION

The RAI demonstrates somewhat less discrimination when applied exclusively to cancer patients, but remains a strong predictor of postoperative mortality, especially in the setting of disseminated cancer.

Association of Routine Preoperative Frailty Assessment With 1-Year Postoperative Mortality

Importance

Patient frailty is a known risk factor for adverse outcomes following surgery, but data are limited regarding whether systemwide interventions related to frailty are associated with improved patient outcomes.

Objective

To evaluate whether a frailty screening initiative (FSI) is associated with reduced late-term mortality after elective surgery.

Design, Setting, and Participants

This quality improvement study with an interrupted time series analysis used data from a longitudinal cohort of patients in a multihospital, integrated health care system in the US. Beginning in July 2016, surgeons were incentivized to measure frailty with the Risk Analysis Index (RAI) for all patients considering elective surgery. Implementation of the BPA occurred in February 2018. The cutoff for data collection was May 31, 2019. Analyses were conducted between January and September 2022.

Exposures

The exposure of interest was an Epic Best Practice Alert (BPA) used to identify patients with frailty (RAI ≥42) and prompt surgeons to document a frailty-informed shared decision-making process and consider additional evaluation by a multidisciplinary presurgical care clinic or the primary care physician.

Main Outcomes and Measures

The primary outcome was 365-day mortality after the elective surgical procedure. Secondary outcomes included 30-day and 180-day mortality as well as the proportion of patients referred for additional evaluation based on documented frailty.

Results

A total of 50 463 patients with at least 1 year of postsurgical follow-up (22 722 before intervention implementation and 27 741 after) were included (mean [SD] age, 56.7 [16.0] y; 57.6% women). Demographic characteristics, RAI score, and operative case mix, as defined by Operative Stress Score, were similar between time periods. After BPA implementation, the proportion of frail patients referred to a primary care physician and presurgical care clinic increased significantly (9.8% vs 24.6% and 1.3% vs 11.4%, respectively; both P < .001). Multivariable regression analysis demonstrated an 18% reduction in the odds of 1-year mortality (0.82; 95% CI, 0.72-0.92; P < .001). Interrupted time series models demonstrated a significant slope change in the rate of 365-day mortality from 0.12% in the preintervention period to -0.04% in the postintervention period. Among patients triggering the BPA, estimated 1-year mortality changed by -4.2% (95% CI, -6.0% to -2.4%).

Conclusions and Relevance

This quality improvement study found that implementation of an RAI-based FSI was associated with increased referrals of frail patients for enhanced presurgical evaluation. These referrals translated to a survival advantage among frail patients of similar magnitude to those observed in a Veterans Affairs health care setting, providing further evidence for both the effectiveness and generalizability of FSIs incorporating the RAI.

Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications

OBJECTIVE

Deep brain stimulation (DBS) improves patients' quality of life in multiple movement disorders and chronic neurodegenerative diseases. There are no published studies assessing frailty's impact on DBS outcomes. We evaluated frailty's impacts on DBS outcomes, comparing discriminative thresholds of the risk analysis index (RAI) to modified frailty index-5 (mFI-5) for predicting Clavien-Dindo complications (CDIV).

METHODS

Patients who underwent DBS between 2015 and 2019 in the ACS-NSQIP registry were included. We employed receiver operating characteristic (ROC) curve to examine the discriminative thresholds of RAI and mFI-5 and multivariable analyses for postoperative outcomes. Our primary outcome was CDIV, and secondary outcomes were discharge to higher-level care facility, unplanned reoperation within 30 days, in any hospital, for any procedure related to the index procedure, and extended length of stay.

RESULTS

A total of 3795 patients were included. In the ROC analysis for CDIV, RAI showed superior discriminative threshold (C-statistic = 0.70, 95% CI 0.61-0.80, <0.001) than mFI-5 (C-statistic = 0.60, 95% CI 0.49-0.70, P = 0.08). On multivariable analyses, frailty stratified by RAI, had independent associations with CDIV, i.e., pre-frail 2-fold increase OR 2.04 (95% CI: 1.94-2.14) p < 0.001, and frail 39% increase OR 1.39 (95% CI: 1.27-1.53), p < 0.001.

CONCLUSION

Frailty was an independent risk-factor for CDIV. The RAI had superior discriminative thresholds than mFI-5 in predicting CDIV after DBS. Our ability to identify frail patients prior to DBS presents a novel clinical opportunity for quality improvement strategies to target this specific patient population. RAI may be a useful primary frailty screening modality for potential DBS candidates.

Frailty measured by risk analysis index and adverse discharge outcomes after adult spine deformity surgery: analysis of 3104 patients from a prospective surgical registry (2011-2020)

BACKGROUND CONTEXT

Measurement of frailty with the Risk Analysis Index (RAI) has demonstrated improved outcome prediction compared to other frailty indices across the surgical literature. However, the generalizability and clinical utility of preoperative RAI scoring for prediction of postoperative morbidity after adult spinal deformity surgery is presently unknown. Thus, recent studies have called for an RAI analysis of spine deformity outcomes.

PURPOSE

The present study sought to evaluate the discriminatory accuracy of preoperative frailty, as measured by RAI, for predicting postoperative morbidity among adult spine deformity surgery patients using data queried from a large prospective surgical registry representing over 700 hospitals from 49 US states and 11 countries.

STUDY DESIGN/SETTING

Secondary analysis of a prospective surgical registry.

PATIENT SAMPLE

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020).

OUTCOME MEASURES

The primary endpoint was "adverse discharge outcome" (ADO) defined as discharge to a non-home, non-rehabilitation nursing/chronic care facility.

METHODS

Adult spine deformity surgeries were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020) using diagnosis and procedure codes. The relationship between increasing preoperative RAI frailty score and increasing rate of primary endpoint (ADO) was assessed with Cochran-Armitage linear trend tests. Discriminatory accuracy was tested by computation of concordance statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 3,104 patients underwent spine deformity surgery and were stratified by RAI score: 0-10: 22%, 11-15: 11%, 16-20: 29%, 21-25: 26%, 26-30: 8.0%, 31-35: 2.4%, and 36+: 1.4%. The rate of ADO was 14% (N=439/3094). The rate of ADO increased significantly with increasing RAI score (p<.0001). RAI demonstrated robust discriminatory accuracy for prediction of ADO in ROC analysis (C-statistic: 0.71, 95% CI: 0.69-0.74, p<.001). In pairwise comparison of ROC curves (DeLong test), RAI demonstrates superior discriminatory accuracy compared to the 5-factor modified frailty index (mFI-5; p<.001).

CONCLUSION

Preoperative frailty, as measured by RAI, is a robust predictor of postoperative morbidity (measured by ADO) after adult spine deformity surgery. The frailty score may be translated directly to the bedside with a user-friendly risk calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spineDeformity.

Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults

Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.

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

Background:

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

Case Description:

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

Conclusion:

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

Surgical Treatment of Nonmelanoma Skin Cancer in Older Adult Veterans

Background

Older adult patients are frequently referred to surgical services for the treatment of nonmelanoma skin cancer (NMSC). The appropriateness of offering surgery to patients with serious comorbidities and a limited life expectancy has been questioned in the literature. The purpose of this study was to determine the morbidity and 5-year mortality for patients with NMSC referred to the plastic surgery service.

Methods

A retrospective chart review was performed from July 1, 2011, to June 30, 2015, of all plastic surgery service consults for the treatment of NMSC. We collected the following data: age and life-limiting comorbidities at the time of referral, treatment, complications, and 5-year mortality. A χ2 analysis was used to determine the statistical significance (P < .05) between the individual risk factors and 5-year mortality. The relative risk of 5-year mortality was calculated combining advanced age with individual comorbidities.

Results

The plastic surgery service completed 800 consults for NMSC over a 4-year period. Five-year mortality was 28.6%. Median age of patients deceased at 5 years was 78 years at the time of the consult submission. The surgical complication rate was 5%. Aged ≥ 80 years, coronary artery disease, congestive heart failure, cerebral vascular disease, peripheral vascular disease, dementia, chronic kidney disease, chronic obstructive pulmonary disease, and diabetes mellitus were found individually to be statistically significant predictors of 5-year mortality. Combining aged ≥ 80 years, coronary artery disease, congestive heart failure, or dementia increased the 5-year mortality to a relative risk > 3.

Conclusions

Surgical excision of NMSC in older adult patients is indicated in most situations. A frank discussion with the patient and caregiver is suggested. Surgical treatment of NMSC in older adult patients has a low morbidity but needs to be balanced against a patient's quality of life when they present with life-limiting comorbidities.

Increased Morbidity and Mortality After Hepatectomy for Colorectal Liver Metastases in Frail Patients is Largely Driven by Worse Outcomes After Minor Hepatectomy: It's Not "Just a Wedge"

BACKGROUND

Frailty is associated with postoperative mortality, but its significance after hepatectomy for colorectal liver metastases (CRLM) is poorly defined. This study evaluated the impact of frailty after hepatectomy for CRLM.

METHODS

The study identified 8477 patients in National Surgical Quality Improvement Program databases from 2014 to 2019 and stratified them by frailty score using the risk analysis index as very frail (>90th percentile), frail (75th-90th percentile), or non-frail (< 75th percentile). Multivariate regression models determined the impact of frailty on perioperative outcomes, including by the extent of hepatectomy.

RESULTS

The procedures performed were 2752 major hepatectomies (left hepatectomy, right hepatectomy, trisectionectomy) and 5725 minor hepatectomies (≤2 segments) for 870 (10.3%) very frail, 1680 (19.8%) frail, and 5927 (69.9%) non-frail patients. Postoperatively, the very frail and frail patients experienced more complications (very frail [41.8%], frail [35.1%], non-frail [31.0%]), which resulted in a longer hospital stay (very-frail [5.7 days], frail [5.8 days], non-frail [5.1 days]), a higher 30-day mortality (very-frail [2.2%], frail [1.3%], non-frail [0.5%]), and more discharges to a facility (very frail [6.8%], frail [3.7%], non-frail [2.6%]) (p < 0.05) although they underwent similarly extensive (major vs. minor) hepatectomies. In the multivariate analysis, frailty was independently associated with complications (very-frail [odds ratio {OR}, 1.70], frail [OR, 1.25]) and 30-day mortality (very-frail [OR, 4.24], frail [OR, 2.41]) (p < 0.05). After minor hepatectomy, the very frail and frail patients had significantly higher rates of complications and 30-day mortality than the non-frail patients, and in the multivariate analysis, frailty was independently associated with complications (very frail [OR, 1.97], frail [OR, 1.27]) and 30-day mortality (very frail [OR, 6.76], frail [OR, 3.47]) (p < 0.05) after minor hepatectomy.

CONCLUSIONS

Frailty predicted significantly poorer outcomes after hepatectomy for CRLM, even after only a minor hepatectomy.

Elevated Risk Analysis Index (RAI) Frailty Scores Are Independently Associated with Adverse Outcomes in Lower Extremity Surgical Revascularizations Similarly Across Genders

INTRODUCTION

The Risk Analysis Index (RAI) frailty scoring system, developed in a predominantly male Veteran sample, has recently undergone revision and external validation to become the RAI-rev using a general surgical sample from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. We set forth to evaluate the application of RAI-rev scoring to lower extremity surgical revascularization outcomes in the NSQIP database while verifying that similar associations with outcomes persist in this subset across genders.

METHODS

All elective cases in the NSQIP Targeted Lower Extremity Open (LEO) database recorded from 2015-2019 were paired with the NSQIP Participant User File using Case IDs. Groups were defined by EMR-recorded gender. Extended length of stay was defined as top quartile postoperative stays. Aggregate demographics, perioperative factors, and 30-day outcomes were compared between groups using unpaired t-test and Fisher's exact test. Adjusted odds-ratios (aOR) for each outcome were generated by applying a multivariate binary logistic regression model in IBM SPSS^TM for five-point RAI-rev score increments from 25-45 and a most-frail group with scores >45. Covariates included surgical indication, prior ipsilateral surgical revascularization versus percutaneous intervention, graft utilization, presence of dirty/infected wound, smoking, hypertension, diabetes, and steroid use. A non-frail group with RAI-rev scores <25 was utilized as the reference for generating adjusted odds ratios.

RESULTS

8,155 cases were recorded in the NSQIP LEO database from 2015-2019, including 2,498 (31%) performed in women who had slightly lower RAI-rev scores on average (22.1±5.8 vs 24.2±5.1; p=0.0001). Univariate trends demonstrated dose-dependent increases in frequency of most outcomes with rising frailty score ranges, with the most substantial changes over mortality (0.4% of non-frail to 14.7% most-frail), disposition to a skilled nursing facility (8% of non-frail to 27% most-frail), and extended length of stay (16% of non-frail to 44% most-frail). After adjusting for co-variates, patients with RAI-rev scores of 26-30 had aOR of 1.4 (95% CI: 1.2-1.6; p<0.001), 1.9 (95% CI: 1.6-2.2; p<0.001), and 2.4 (95% CI: 1.3-4.4; p<0.001) for extended stay, disposition to skilled nursing, and mortality respectively as compared to those with RAI-rev scores <25. Despite more non-significant aOR for women than men, trends were similar across genders in both univariate and multivariate analyses.

CONCLUSION

Our study is the first to find that outcomes other than mortality are significantly predicted by RAI-rev score ranges in lower extremity surgical revascularizations with similar associations regardless of gender. RAI-rev frailty scores >30 may help to identify frail patients at a higher risk of mortality, extended stay, and increased rehabilitation needs prior to lower extremity surgical revascularization to inform risk assessment and optimize patient recovery.

The impact of frailty on mortality in non-surgical head and neck cancer treatment: Shifting the clinical paradigm

OBJECTIVE

Compare survival of head and neck cancer (HNC) patients treated with surgical or non-surgical management according to frailty, quantify frailty with the Risk Analysis Index (RAI), a validated 14-item instrument.

MATERIALS AND METHODS

Prospective cohort study of newly diagnosed HNC patients (≥18 years) who had frailty assessment from April 13, 2016 to September 30, 2016. Primary outcome was overall survival at 1- and 3-years. Cox proportional hazard models were utilized to examine mortality with predictor variables. Adjusted and unadjusted (Kaplan-Meier) survival curves stratified by either RAI scores or treatment modality were plotted. Kruskal-Wallis and likelihood ratio chi-square tests were used for comparing clinicodemographic variables.

RESULTS

Of 165 patients, 54 (32.7%) were managed non-surgically, 49 (29.7%) were treated with definitive surgery only, and 62 (37.6%) were treated with multimodality (surgery + adjuvant) therapy. Among the full cohort and subgroup analysis of the frail/very frail (RAI ≥ 37), non-surgical patients had worse or similar 3-year survival than those treated with surgery +/- adjuvant therapy. Multivariable Cox proportional hazard models demonstrate that frail patients treated non-surgically experienced worse survival than their counterparts treated with surgery (HR = 2.50, p = 0.015, 95% CI: 1.19, 5.23) or multimodality therapy (HR = 3.91, p < 0.001, 95% CI: 1.94-7.89).

CONCLUSION

Across all levels of frailty, long term survival of HNC patients treated without surgery is either worse than or like those treated with surgery. These findings (1) challenge current practices of steering patients "too frail for surgery" towards non-surgical, "non-invasive" therapy, and (2) suggest equipoise warranting randomized trials to clarify treatment of frail patients.

Association Between Hospital Perioperative Quality and Long-term Survival After Noncardiac Surgery

IMPORTANCE

There is known variation in perioperative mortality rates across hospitals. However, the extent to which this variation is associated with hospital-level differences in longer-term survival has not been characterized.

OBJECTIVE

To evaluate the association between hospital perioperative quality and long-term survival after noncardiac surgery.

DESIGN, SETTING, AND PARTICIPANTS

This national cohort study included 654 093 US veterans who underwent noncardiac surgery at 98 hospitals using data from the Veterans Affairs Surgical Quality Improvement Program from January 1, 2011, to December 31, 2016. Data were analyzed between January 1 and November 1, 2021.

EXPOSURES

Hospitals were stratified separately into quintiles of reliability-adjusted failure to rescue (FTR) and mortality rates. Patients were further categorized as having a complicated or uncomplicated postoperative course.

MAIN OUTCOMES AND MEASURES

The association between hospital FTR or mortality performance quintile (with quintile 1 representing low FTR or mortality and quintile 5 representing very high FTR or mortality) and overall risk of death was evaluated separately using multivariable shared frailty modeling among patients with a complicated and uncomplicated postoperative course.

RESULTS

For the overall cohort of 654 093 patients, the mean (SD) age was 61.1 (13.2) years; 597 515 (91.4%) were men and 56 578 (8.7%) were women; 111 077 (17.0%) were Black, 5953 (0.9%) were Native American, 467 969 (71.5%) were White, 42 219 (6.5%) were missing a racial category, and 26 875 (4.1%) were of another race; and 37 538 (5.7%) were Hispanic. Hospital-level 5-year survival for patients with a complicated course ranged from 42.7% (95% CI, 38.1%-46.9%) to 82.4% (95% CI, 59.0%-93.2%) and from 76.2% (95% CI, 74.4%-78.0%) to 95.2% (95% CI, 92.5%-97.7%) for patients with an uncomplicated course. Overall, 47 (48.0%) and 83 (84.7%) of 98 hospitals were either in the same or within 1 performance quintile for FTR and mortality, respectively. Among patients who had a postoperative complication, there was a dose-dependent association between care at hospitals with higher FTR rates and risk of death (compared with quintile 1: quintile 2 hazard ratio [HR], 1.05 [95% CI, 0.99-1.12]; quintile 3 HR, 1.17 [95% CI, 1.10-1.26]; quintile 4 HR, 1.30 [95% CI, 1.22-1.38]; and quintile 5 HR, 1.34 [95% CI, 1.22-1.43]). Similarly, increasing hospital FTR rates were associated with increasing risk of death among patients without complications (compared with quintile 1: quintile 2 HR, 1.07 [95% CI, 1.01-1.14]; quintile 3 HR, 1.10 [95% CI, 1.04-1.16]; quintile 4 HR, 1.15 [95% CI, 1.09-1.21]; and quintile 5 HR, 1.10 [95% CI, 1.05-1.19]). These findings were similar across hospital mortality quintiles for patients with complicated and uncomplicated courses.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that the structures, processes, and systems of care that underlie the association between FTR and worse short-term outcomes may also have an influence on long-term survival through a pathway other than rescue from complications. A better understanding of these differences could lead to strategies that address variation in both perioperative and longer-term outcomes.

Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery

Importance

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking.

Objective

To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals.

Design, Setting, and Participants

This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included.

Exposures

Surgical care in either a VA or private sector setting.

Main Outcomes and Measures

Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication.

Results

Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding.

Conclusions and Relevance

VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.

Surgical risk calculators in veterans following lower extremity amputation

OBJECTIVE

To evaluate the accuracy of multiple risk calculators for 30-day mortality on patients undergoing major lower extremity amputation.

METHODS

The actual 30-day mortality at a single Veterans Affairs institution was compared to the predicted outcome from the following risk calculators: ACS-NSQIP, VASQIP, amputation scoring tool (AST), and POTTER elective.

RESULTS

The overall calculated 30-day mortality was similar to the actual mortality with the VASQIP and POTTER elective risk calculators, while the NSQIP and AST over-estimated the 30-day mortality. The predictive accuracy of the POTTER and NSQIP risk calculators were moderate (AUC >0.7), and fair for the VASQIP and AST.

CONCLUSION

Risk assessment tools can provide adjunctive data on predicted 30-day mortality in patients undergoing major lower extremity amputation. In our study, there were differences in predictability of the risk calculators for lower extremity amputation that should be considered when utilizing a risk assessment tool to improve physician-patient shared decision-making.

Using the risk analysis index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair

OBJECTIVE

Surgical frailty is strongly associated with increased perioperative morbidity and mortality. The risk analysis index (RAI) is a validated frailty score system, which has been shown to predict for short-term outcomes and long-term mortality in various surgical subspecialties. In the present study, we applied the frailty score to a veteran aneurysm population who had undergone nonemergent endovascular aortic aneurysm repair (EVAR).

METHODS

After obtaining institutional review board approval, the Veteran Affairs Surgical Quality Improvement Program data were queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection using the Current Procedural Terminology codes 34,800, 34,803, and 34,805 from 2001 to 2018. The preoperative variables were used to calculate the RAI score. The patients were placed into six cohorts according to the RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). The χ² test and analysis of variance test were used compare the cohorts. Forward logistic regression modeling was used to determine the risks of each cohort.

RESULTS

From 2001 to 2018, 5568 patients had undergone EVAR. Of the 5568 patients, 99.6% were male, with a mean age of 71 ± 8 years. Of these patients, 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% were included in the following RAI groups: ≤20, 21 to 25, 26 to 30, 31 to 35, 35 to 40, and ≥41, respectively. Frailty was associated with increased rates of overall complications, death, and an increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated with 2.7 times the odds of any complication developing and 4.4 times the odds of mortality ≤30 days.

CONCLUSIONS

Frailty, as determined by the RAI, was associated with postoperative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean from ventilation, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients scheduled to undergo EVAR.