Association between an electronic health record (EHR)–embedded frailty index and survival among older adults receiving cancer chemotherapy

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Background: Innovative strategies to facilitate rapid frailty screening are critically needed to enhance personalized oncology care among vulnerable older patients. An electronic frailty index (eFI) holds promise as a passive measure of frailty. The eFI was initially designed for primary care. The objective of this study was to establish feasibility, estimate prevalence of frailty, and evaluate the predictive value of the eFI for overall survival (OS) among older adults with cancer planned to receive chemotherapy. Methods: Consecutive patients (N = 509) aged 65+ with newly diagnosed lung, colorectal or breast cancer treated with chemotherapy were identified from our cancer registry between 2017 and 2020. Calculation of the eFI requires at least two ambulatory visits over a 2-year period and utilizes demographic information, vital signs, smoking status, ICD-10 diagnosis codes, select outpatient laboratory measurements, and functional information (if available from Medicare Annual Wellness Visits) during the 2 years prior to diagnosis. Frailty status is categorized as fit (eFI ≤0.10), pre-frail (0.10 < eFI≤0.21), and frail (eFI > 0.21) based on the proportion of deficits present over the total number evaluated (score range 0-1). Non-calculable scores indicate insufficient historical primary care data within two years prior to cancer diagnosis. OS was estimated by eFI category using Kaplan Meier curves and compared using log rank testing. Cox proportional hazards models evaluated the adjusted association between eFI categories and mortality. Results: The cohort included 509 adults (median age 72.2 yrs, 55% female, 83.5% white, 13.4% black, 45.8% stage 4) with lung (N = 312), colorectal (N = 111) and breast (N = 86) cancer. Distribution of eFI categories at diagnosis were fit (25.9%), pre-frail (41.1%), frail (17.3 %) and not calculable (15.7%). The proportion of patients categorized as “fit” differed by disease type (19.9% lung, 30.6% colorectal, 41.9% breast, p < 0.0001). In univariate analyses, eFI frailty category was associated with OS (median OS for fit, pre-frail, frail and not calculable were > 54, 25, 19 and 10 months respectively, p < 0.0001.). Adjusting for age, gender, race, stage, and cancer type, the hazard of death was higher for pre-frail (Hazard Ratio, [HR] 1.7, 95% Confidence Interval [CI] 1.2-2.4), frail (HR 2.3, 95% CI 1.5-3.4) and not calculable eFI categories (HR 2.8, 95% CI 1.8-4.2) compared to fit patients. Conclusions: Calculating an EHR embedded eFI at the time of diagnosis among older adults treated with chemotherapy was feasible and identified nearly one-fifth of patients as frail. eFI-defined frailty status was associated with survival, with poorer survival among the most frail supporting eFI validity. The eFI is a promising scalable tool to efficiently conduct frailty screening in oncology clinical practice.

Gender diversity in United States neurosurgery training programs

OBJECTIVE

Neurosurgery continues to be one of the medical specialties with the lowest representation of females in both the resident and faculty workforce. Currently, there are limited available data on the gender distribution of faculty and residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery training programs. This information is critical to accurately measure the results of any effort to improve both the recruitment and retention of women in neurosurgery. The objective of the current study was to define the current gender distribution of faculty and residents in ACGME-accredited neurosurgery training programs.

METHODS

Data publicly available through institutional and supplemental websites for neurosurgical faculty and residents at ACGME-accredited programs were analyzed for the 2017-2018 academic year. Data collected for faculty included gender, age, year of residency graduation, academic rank, h-index, American Board of Neurological Surgery certification status, and leadership positions. Resident data included gender and postgraduate year of training.

RESULTS

Among the 109 ACGME-accredited neurosurgical residency programs included in this study, there were 1350 residents in training, of whom 18.2% were female and 81.8% were male. There are 1320 faculty, of whom 8.7% were female and 91.3% were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Female faculty were younger, had lower h-indices, and were less likely to be board certified and attain positions of higher academic rank and leadership.

CONCLUSIONS

This study serves to provide a current snapshot of gender diversity in ACGME-accredited neurosurgery training programs. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, the authors' findings suggest that this is likely due to the small number of women in the neurosurgical field who are the farthest away from residency graduation and serves to highlight the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce.