Effective Risk Assessment for Distal Radius Fractures: A Rigorous Multivariable Regression Analysis, Using a Novel 8-Item Modified Frailty Index

Introduction  Distal radius fractures (DRFs) are among the most common orthopaedic injuries. The prevalence of DRFs is increasing across all age groups but remains the second most common fracture in the elderly. The modified frailty index (MFI) often predicts morbidity and mortality in orthopaedic injuries. This study aims to determine the predictive value of MFI on complication rates following DRF and the patient length of stay and discharge outcomes. Methods  We utilized our MFI to perform a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Results  In a total of 22,313 patients, the average age was 46 ± 16. An increase in MFI led to an increase in the odds ratio of readmission and reoperation ( p  < 0.001). MFI predicted complications, doubling the rate as the score increased from 1 to 2 ( p  < 0.001). An MFI of 2 also led to a delayed hospital stay of 5 days ( p  < 0.001), as well as an increase in the odds of patients not being sent home at discharge ( p  < 0.001). Finally, life-threatening complications were also predicted with an increased MFI, the odds of a life-threatening complication increasing 488.20 times at an MFI of 3 ( p  < 0.001). Discussion and Conclusion  While surgical decision-making for frail patients with DRFs remains contentious, this novel 8-item MFI score was significantly associated with the probability of hospital readmission/reoperation, postoperative complications, and delayed hospital length of stay. Three new parameters were incorporated into our 8-item score compared with the conventional 5; hypoalbuminemia status (< 3.5 mg/dL), previous diagnosis of osteoporosis, and severe obesity (body mass index > 35) enhancing its sensitivity. Future studies are warranted for its prospective utility in ruling out postsurgical comorbidity.

Surgical excision and radiotherapy for brain metastasis from colorectal cancer: How frailty and comorbidity indices influence outcome

The incidence of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study aims to identify the clinical prognosticators and evaluate the prognostic validity of common comorbidity indices in patients with BM from CRC. This retrospective single-center study analyzed 93 patients with BM from CRC who received surgical excision and/or radiotherapy. The clinical characteristics and prognostic indices including the 5-item modified frailty index (mFI-5) and prognostic nutritional index (PNI) were calculated from the collected patient data and analyzed. In this study, 66 (71.0%), 10 (10.8%), and 17 (18.3%) patients received whole-brain radiotherapy (WBRT) alone, surgery alone, and surgery plus WBRT, respectively. The median survival of all patients was 3.98 months (IQR: 1.74-7.99). The 2- and 3-year survival rates were 7.4% and 3.7%, respectively. Controlled primary tumor (p = 0.048), solitary BM (p = 0.001), surgery + radiation (p < 0.001), and greater PNI (p = 0.001) were independent predictors of favorable survival. In surgically treated patients, uncontrolled primary tumor (p = 0.006), presence of multiple BM (p < 0.001), and MFI-5 ≥ 2 (p = 0.038) were independent prognosticators. For patients who received WBRT, the presence of two (p = 0.004) or multiple (p < 0.001) BM and PNI (p < 0.001) were independent survival predictors MFI-5, multiple BM, and the status of the primary tumor were independent prognosticators for patients who underwent surgery for CRCBM. For patients who received WBRT, the PNI and the number of BM were independent survival predictors.

Utility of the Modified 5-Items Frailty Index to Predict Complications and Mortality After Elective Cervical, Thoracic and Lumbar Posterior Spine Fusion Surgery: Multicentric Analysis From ACS-NSQIP Database

STUDY DESIGN

Retrospective review of multicentric data.

OBJECTIVES

The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. It has been recently shown a good predictive value after posterior lumbar fusion. We aimed to compare the predictive value of the modified 5-item frailty index in cervical, thoracic and lumbar surgery.

METHODS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database 2015-2020 was used to identify patients who underwent elective posterior cervical, thoracic, or lumbar fusion surgeries for degenerative conditions. The mFI-5 score was calculated based on the presence of 5 co-morbidities: congestive heart failure within 30 days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on the postoperative morbidity while controlling for baseline clinical characteristics.

RESULTS

53 252 patients were included with the mean age of 64.2 ± 7.2. 7946 suffered medical complications (14.9%), 1565 had surgical complications (2.9%), and 3385 were readmitted (6.3%), 363 died (.68%) within 30 days postoperative (6.3%). The mFI-5 items score was significantly associated with higher rates of complications, readmission, and mortality in cervical, thoracic, and lumbar posterior fusion surgery.

CONCLUSION

The modified 5-item frailty score is a reliable tool to predict complications, readmission, and mortality in patients planned for elective posterior spinal fusion surgery.

The Impact of Frailty on Surgical Outcome of Patients with Lumbar Spinal Canal Stenosis

Introduction

Frailty is an important factor in surgical outcomes. The current study aimed to evaluate the effect of preoperative frailty on postoperative outcomes in older patients with lumbar spinal canal stenosis (LSCS).

Methods

We retrospectively examined 209 patients aged ≥65 years who underwent surgery for LSCS. Health-related quality-of-life (HRQOL) tools, including the Roland-Morris Disability Questionnaire (RDQ), Zurich Claudication Questionnaire (ZCQ), and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), were used in the assessment conducted before surgery and at 6 months and 1 year after surgery. Frailty was categorized based on the 11-item modified frailty index (mFI-11). Patients with mFI-11 of 0, <0.21, and >0.21 were classified under the robust (R), pre-frailty (P), and frailty (F) groups, respectively.

Results

According to the mFI-11, 24, 138, and 47 patients were included in the R, P, and F groups, respectively. Regarding preoperative radiographic parameters, there was a remarkable increase in the sagittal vertical axis and a significant decrease in the development of lumbar lordosis with frailty progression. The preoperative scores of RDQ and ZCQ, and lumbar function, walking ability, social life, and psychological disorder domain scores of JOABPEQ differed significantly among these groups. The frequency of revision surgery was not higher in the F group than in the other groups. After adjustment for factors have shown different distributions among the three groups, the frequency of effective surgical cases did not show a clear trend among the three groups in all domains of the JOABPEQ.

Conclusions

The preoperative HRQOL scores and the radiographic parameters of patients with LSCS worsened with frailty severity. However, frailty did not affect the rate of revision surgery and surgical efficacy in patients with LSCS. Although this study has limitations, our findings indicated that even LSCS patients with frailty can be considered for surgery if they have an indication for LSCS surgery.

The 5-Factor Modified Frailty Index is a succinct yet effective predictor of adverse outcomes in patients undergoing open surgery for abdominal aortic aneurysm

BACKGROUND

Frailty is an age-related, clinically recognizable state marked by increased susceptibility. The 5-item Modified Frailty Index (mFI-5) offers a concise assessment of frailty and has demonstrated its efficacy in various surgical fields. While the mFI-5 has been validated for Endovascular Aneurysm Repair (EVAR) for Abdominal Aortic Aneurysm (AAA), its applicability in open surgical repair (OSR) for AAA remains largely unexplored. This study sought to evaluate the utility of mFI-5 in predicting 30-day outcomes following OSR for AAA.

METHODS

Patients underwent OSR for AAA were identified in ACS-NSQIP targeted database from 2012-2021. Patients were stratified into three cohorts: mFI-5 score of 0 (control), 1, and 2+. Multivariable logistic regression was used to compare 30-day perioperative outcomes between frail patients and controls adjusting preoperative variables with p-value<0.1.

RESULTS

Of the 5,249 patients who underwent OSR for AAA, 1,043 were controls, 2,938 had an mFI-5 score of 1, and 1,268 had an mFI-5 score of 2+. When compared to the control group, patients with an mFI-5=1 were more likely to have pulmonary events (aOR=1.452, p<0.01), bleeding events (aOR=1.33, p<0.01), wound complications (aOR=2.214, p<0.01), ischemic colitis (aOR=1.616, p=0.01), and unplanned reoperation (aOR=1.292, p=0.04). Those with an mFI-5=2+ demonstrated higher risks of mortality (aOR=1.709, p<0.01), MACE (aOR=1.347, p=0.04), pulmonary events (aOR=2.045, p<0.01), renal dysfunction (aOR=1.568, p<0.01), sepsis (aOR=1.587, p=0.01), bleeding events (aOR=1.429, p<0.01), wound complications (aOR=2.338, p<0.01), ischemic colitis (aOR=1.775, p=0.01), unplanned reoperation (aOR=1.445, p=0.01), operation over 4 hours (aOR=1.34, p<0.01), length of stay over 7 days (aOR=1.324, <0.01), discharge not to home (aOR=1.547, p<0.01), 30-day readmission (aOR=1.657, p=0.01).

CONCLUSION

The mFI-5 emerges as a succinct yet effective indicator of frailty for patients undergoing OSR for AAA. Especially, a mFI-5 score of 2+ is linked with increased 30-day mortality and complications. As such, mFI-5 can be used as a valuable screening tool for frailty in patients undergoing OSR for AAA.

Posterior Instrumented Spinal Surgery Outcomes in the Elderly: A Comparison of the 5-Item and 11-Item Modified Frailty Indices

STUDY DESIGN

Retrospective Cohort.

OBJECTIVES

To validate the most concise risk stratification system to date, the 5-item modified frailty index (mFI-5), and compare its effectiveness with the established 11-item modified frailty index (mFI-11) in the elderly population undergoing posterior instrumented spine surgery.

METHODS

A single centre retrospective review of posterior instrumented spine surgeries in patients aged 65 years and older was conducted. The primary outcome was rate of post-operative major complications (Clavien-Dindo Classification ≥ 4). Secondary outcome measures included rate of all complications, 6-month mortality and surgical site infection. Multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated and compared by DeLong's test. The indices were correlated with Spearman's rho.

RESULTS

272 cases were identified. The risk of major complications was independently associated with both the mFI-5 (OR 1.89, 95% CI 1.01-3.55, P = .047) and mFI-11 (OR 3.73, 95% CI 1.90-7.30, P = .000). Both the mFI-5 and mFI-11 were statistically significant predictors of risk of all complications (P = .007 and P = .003), surgical site infection (P = .011 and P = .003) and 6-month mortality (P = .031 and P = .000). Adjusted ROC curves determined statistically similar c-statistics for major complications (.68 vs .68, P = .64), all complications (.66 vs .64, P = .10), surgical site infection (.75 vs .75, P = .76) and 6-month mortality (.83 vs .81, P = .21). The 2 indices correlated very well with a Spearman's rho of .944.

CONCLUSIONS

The mFI-5 and mFI-11 are equally effective predictors of postoperative morbidity and mortality in this population. The brevity of the mFI-5 is advantageous in facilitating its daily clinical use.

Modified Frailty Index as a Predictor of Adverse Outcomes in Elective Primary Hip and Knee Replacement Surgery Patients at a Tertiary Care Hospital in Pakistan: A Cross-Sectional Study

Objective The objective was to evaluate the modified frailty index as a predictor of early (within 30 days) postoperative complications in total joint arthroplasty patients, in a low middle-income country. Material and methods A cross-sectional study was carried out which included patients with ages ranging from 23 to 86 years, who underwent elective primary Total Hip or Knee Arthroplasties (TKA or THA) between December 2021 and February 2023. Modified frailty index (mFI-5) was calculated and 30-day morbidity and mortality were recorded. Post-operative complications were categorized as either surgical or medical and recorded. Results A total of 175 patients were included, amongst whom the majority were females (68.6%, n=120) and the mean age was 60.5 ± 13.2 years. 85 patients (48.6%) had a mFI-5 score of one while 48 patients (27.4%) had a score of two. Superficial surgical site infection was the most common complication overall in 6 patients (3.4%); however, no case of prosthetic joint infection was noted. Deep vein thrombosis (DVT) was the most common medical complication (1.7%, n=3). 5 patients (2.9%) required re-admission and two mortalities were recorded within the 30-day interval. A significant association was noted between post-operative surgical complications and mFI-5 score (p-value = < 0.001), with the risk of complications increasing with a higher mFI-5 score. Smoking was noted to be a risk factor for post-operative medical complications as well as 30-day mortality. Conclusion The current study shows that the mFI-5 index can effectively be used as a predictor of postoperative complications in the South Asian region such as Pakistan. This should be calculated routinely and can be used as a tool for pre-operative assessment and counseling.

Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies

OBJECTIVE

The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications.

STUDY DESIGN

Retrospective database review.

SETTING

United States hospitals.

METHODS

The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications.

RESULTS

A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001).

CONCLUSION

This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.

Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair

BACKGROUND

The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs.

METHODS

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility.

RESULTS

2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis.

CONCLUSIONS

Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.

Association between frailty and locomotive syndrome in elderly patients with lumbar spinal stenosis: A retrospective longitudinal analysis

AIMS

With the aging society worldwide, lumbar spinal stenosis (LSS) has become common, and its incidence has been increasing worldwide. Frailty and locomotive syndrome significantly overlap as disorders in older people. The current study aimed to validate the association between frailty and locomotive syndrome in patients with LSS. In particular, the involvement of frailty in locomotive syndrome following surgery was examined.

METHODS

We retrospectively reviewed the time-course data of consecutive patients aged ≥65 years who underwent lumbar spinal surgery for LSS. The locomotive syndrome stages were determined using the 25-Question Geriatric Locomotive Function Scale: stage 0, score ≤6; stage 1, score ≥7; stage 2, score ≥16; and Stage 3, score ≥24. Robust, pre-frailty, and frailty were defined as a modified frailty index-11 score of 0, <0.21, and >0.21, respectively.

RESULTS

This study included 234 patients. All patients except one were diagnosed with locomotive syndrome preoperatively. Approximately 24.8% of participants were diagnosed with frailty. LSS surgery improved locomotive syndrome regardless of frailty severity. Meanwhile, multivariable analysis indicated that frailty could significantly inhibit improvement in locomotive syndrome after surgery in old patients with LSS (estimated relative risk: 0.6; 95% confidence interval: 0.4-0.9).

CONCLUSIONS

This study first assessed the association between locomotive syndrome and frailty in patients with LSS. Locomotive syndrome could be managed effectively with surgery regardless of frailty severity in old patients with LSS. However, our findings emphasize the need to screen for frailty preoperatively in this patient group. Geriatr Gerontol Int 2024; 24: 116-122.

Associations of Frailty with Neuropsychiatric Symptoms of Alzheimer's Disease: A Longitudinal Study

Background

Frailty is a vulnerability state increasing the risk of many adverse health outcomes, but little is known about the effects of frailty on neuropsychiatric health.

Objective

To explore the associations between frailty and the risk of neuropsychiatric symptoms (NPSs) in Alzheimer's disease (AD), especially in its different clinical stages.

Methods

We included 2,155 individuals assessed using modified frailty index-11 (mFI-11), Neuropsychiatric Inventory (NPI) and Neuropsychiatric Inventory Questionnaire (NPI-Q) in the Alzheimer's Disease Neuroimaging Initiative (ADNI). The relationships between frailty and NPSs were explored with logistic regression models and Cox proportional hazard regression models. Causal mediation analyses were conducted to explore the mediation factors between frailty and NPSs.

Results

Among mild cognitive impairment (MCI) participants, frailty was cross-sectionally associated with an increased risk of apathy, and longitudinally associated with increased risk of depression and apathy. Among AD participants, frailty was cross-sectionally associated with increased risk of depression and anxiety, and longitudinally associated with an increased risk of apathy. Among participants with cognitive progression, frailty was associated with increased risk of depression and apathy. In MCI participants, the influence of frailty on NPSs was partially mediated by hippocampus volume, whole brain volume, and monocytes, with mediating proportions ranging from 8.40% to 9.29%.

Conclusions

Frailty was associated with NPSs such as depression, anxiety, and apathy among MCI, AD, and cognitive progression participants. Atrophy of the hippocampus and whole brain, as well as peripheral immunity may be involved in the potential mechanisms underlying the above associations.

Association of Frailty with Adverse Outcomes in Patients with Critical Acute Myocardial Infarction: A Retrospective Cohort Study

Background

Frailty is a risk factor for acute myocardial infarction (AMI). This study examined the association between the modified frailty index (MFI) and adverse outcomes in patients with critical AMI.

Methods

Data were obtained from the Medical Information Mart for Intensive Care IV database. Logistic and Cox regression models and a competing risk model were applied.

Results

Of 5003 patients, 1496 were non-frail and 3507 were frail. Frailty was significantly associated with in-hospital mortality (per point, OR 1.13, 95% CI: 1.05-1.21; frail vs non-frail, OR 1.31, 95% CI: 1.04-1.65) and 1-year mortality (per point, HR 1.15, 95% CI: 1.11-1.20; frail vs non-frail, HR 1.37, 95% CI: 1.20-1.58). Frailty was significantly associated with post-discharge care needs (per point, OR 1.23, 95% CI: 1.14-1.33; frail vs non-frail, OR 1.47, 95% CI: 1.22-1.78). In the competing risk models, frailty was significantly associated with a lower probability of being discharged from the ICU (per point, HR 0.87, 95% CI: 0.85-0.90; frail vs non-frail, HR 0.73, 95% CI: 0.68-0.79) and hospital (per point, HR 0.82, 95% CI: 0.80-0.85; frail vs non-frail, HR 0.62, 95% CI: 0.57-0.68). Subgroup analyses showed the association of frailty with in-hospital and 1-year mortality was stronger in patients with a SOFA score ≤2 than in those with a SOFA score >2 (both p<0.05 for interaction).

Conclusion

Frailty assessed by the MFI was an independent predictor of adverse outcomes in patients with critical AMI and may be helpful for prognostic risk stratification.

Evaluation of postoperative outcomes of minimally invasive distal pancreatectomy for left-sided pancreatic tumors based on the modified frailty index: a retrospective cohort study

BACKGROUND

This study compared the postoperative outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors based on the modified frailty index (mFI).

MATERIALS AND METHODS

This retrospective study included 2212 patients who underwent MIDP for left-sided pancreatic tumors between 2005 and 2019. Postoperative outcomes, including complications (morbidity and mortality), were analyzed using mFI, and the participants were divided into two groups: frail ( n =79) and nonfrail ( n =2133). A subanalysis of 495 MIDPs for pancreatic ductal adenocarcinoma was conducted to compare oncological outcomes.

RESULTS

Clinically relevant postoperative pancreatic fistula was significantly higher in the frail group than in the nonfrail group. A significant between-group difference was observed in overall complications with Clavien-Dindo classification grade ≥III. Furthermore, the proportion of all complications before readmission was higher in the frail group than in the nonfrail group. Among all readmitted patients, the frail group had a higher number of grade ≥IV patients requiring ICU treatment. The frail group's 90-day mortality was 1.3%; the difference was statistically significant (nonfrail: 0.3%, P =0.021). In the univariate and multivariate logistic regression analyses, mFI ≥0.27 (odds ratio 3.231, 95% CI: 1.889-5.523, P <0.001), extended pancreatectomy, BMI ≥30 kg/m 2 , male sex, and malignancy were risk factors for Clavien-Dindo classification grade ≥III.

CONCLUSION

mFI is a potential preoperative tool for predicting severe postoperative complications, including mortality, in patients who have undergone MIDP for left-sided tumors.

Modified Frailty Index and Albumin-Fibrinogen Ratio Predicts Postoperative Seroma After Laparoscopic TAPP

Background

Postoperative seroma is the most common minor complication after inguinal hernia repair surgery and can have negative consequences. The objective of this study was to identify potential risk factors for postoperative seroma.

Methods

This study consecutively included 354 elderly patients with inguinal hernia who underwent laparoscopic Transabdominal preperitoneal Patch Plasty (TAPP). Seroma diagnosis was conducted by the same experienced surgeon based on the physical examinations combined with ultrasound. Risk factors for seroma were identified through univariate analysis and subsequently included in the binary multivariate logistic regression model.

Results

A total of 40 patients experienced postoperative complications of seroma, with an incidence rate of 11.3% (40/354). The binary logistic regression analysis revealed that obesity (OR: 2.98, 95% CI: 1.20-7.41, P = 0.018), disease duration ≥ 4.5 years (OR: 4.88, 95% CI: 2.14-11.18, P < 0.001), albumin-fibrinogen ratio (AFR) level < 9.25 (OR: 6.13, 95% CI: 2.00-18.76, P = 0.001), and modified frailty index (mFI) score ≥ 0.225 (OR: 6.38, 95% CI: 2.69-15.10, P < 0.001) were four independent risk factors for postoperative seroma.

Conclusion

Obesity, prolonged disease duration, decreased AFR level, and increased mFI score independently predict postoperative seroma after laparoscopic TAPP.

The 5-Factor Modified Frailty Index is Associated With Increased Risk of Reoperations and Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To determine the predictive capability between the 5-factor modified frailty index (mFI-5) scores and adverse clinical and radiographic outcomes following single-level transforaminal lumbar interbody fusion (TLIF).

METHODS

All patients over the age of 50 undergoing single-level open or minimally invasive TLIF from 2012 to 2021 with a minimum follow-up of 1 year were identified. Deformity, trauma, emergency, and tumor cases were excluded as were patients undergoing revision surgeries. An mFI-5 score was computed for each patient using a set of five factors which included hypertension requiring medication, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and partially or fully dependent functional status. Univariate and multivariate logistic regression analysis were performed to evaluate the impact of mFI-5 scores on readmissions, reoperations, and postoperative complications.

RESULTS

156 patients were included and grouped according to their level of frailty: no-frailty (mFI = 0, n = 67), mild frailty (mFI = 1, n = 59), and severe frailty (mFI = 2+, n = 30). Multivariate analysis found high levels of frailty (mFI = 2+) to be independent predictors of reoperation (OR: 16.9, CI: 2.7 - 106.9, P = .003) and related readmissions (OR = 16.5, CI: 2.6 - 102.7, P = .003) as compared to the no-frailty group. An mFI-5 score of 2+ was also predictive of any complication (OR = 4.5, CI: 1.4 - 14.3, P = .01) and adjacent segment disease (ASD) (OR = 12.5, CI: 1.2 - 134.0, P = .037).

CONCLUSION

High levels of frailty were predictive of related readmissions, reoperations, any complications, and ASD in older adult patients undergoing single-level TLIF.

Frailty stratification using the Modified 5-item frailty index: Significant variation within frailty patients in spine surgery

BACKGROUND

Frailty status has been associated with higher rates of complications after spine surgery. However, frailty patients constitute an heterogeneous group based on the combinations of comorbidities. The objective of this study is to compare the combinations of variables that compose the modified 5-factor frailty index score (mFI-5) based on the number of comorbidities in terms of complications, reoperation, readmission, and mortality after spine surgery.

METHODS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database from 2009-2019 was used to identify patients who underwent elective spine surgery. The mFI-5 item score was calculated and patients were classified according to number and combination of comorbidities. Multivariable analysis was used to assess the independent impact of each combination of comorbidities in the mFI-5 score on the risk of complications.

RESULTS

A total of 167, 630 patients were included with a mean age of 59.9 ± 13.6 years. The risk of complications was the lowest in patients with diabetes + hypertension (OR=1.2) and highest in those with the combination of CHF, diabetes, COPD, and dependent status (OR=6.6); there was a high variation in complication rate based on specific combinations.

CONCLUSION

There is high variability in terms of relative risk of complications based on the number and combination of different comorbidities, especially with CHF and dependent status. Therefore, frailty status encompasses a heterogeneous group and sub-stratification of frailty status is necessary to identify patients with significantly higher risk of complications.

A comparison of three approaches to measuring frailty to determine adverse health outcomes in critically ill patients

BACKGROUND

studies comparing different frailty measures in intensive care unit settings are lacking. We aimed to compare the frailty index based on physiological and laboratory tests (FI-Lab), modified frailty index (MFI) and hospital frailty risk score (HFRS) to predict short-term outcomes for critically ill patients.

METHODS

we conducted a secondary analysis of data from the Medical Information Mart for Intensive Care IV database. Outcomes of interest included in-hospital mortality and discharge with need for nursing care.

RESULTS

the primary analysis was conducted with 21,421 eligible critically ill patients. After adjusting for confounding variables, frailty as diagnosed by all three frailty measures was found to be significantly associated with increased in-hospital mortality. In addition, frail patients were more likely to receive further nursing care after being discharged. All three frailty scores could improve the discrimination ability of the initial model generated by baseline characteristics for adverse outcomes. The FI-Lab had the best predictive ability for in-hospital mortality, whereas the HFRS had the best predictive performance for discharge with need for nursing care amongst the three frailty measures. A combination of the FI-Lab with either the HFRS or MFI improved the identification of critically ill patients at increased risk of in-hospital mortality.

CONCLUSIONS

frailty, as assessed by the HFRS, MFI and FI-Lab, was associated with short-term survival and discharge with need for nursing care amongst critically ill patients. The FI-Lab was a better predictor of in-hospital mortality than the HFRS and MFI. Future studies focusing on FI-Lab are warranted.

Risk Stratification of Elderly Patients Undergoing Spinal Surgery Using the Modified Frailty Index

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

To validate the 11-item modified Frailty Index (mFI) as a perioperative risk stratification tool in elderly patients undergoing spine surgery.

METHODS

All consecutive cases of spine surgery in patients aged 65 years or older between July 2016 and June 2018 at a state-wide trauma center were retrospectively reviewed. The primary outcome was post-operative major complication rate (Clavien-Dindo Classification ≥ III). Secondary outcome measures included the rate of all complications, 6-month mortality and surgical site infection.

RESULTS

A total of 348 cases were identified. The major complication rate was significantly lower in patients with an mFI of 0 compared to ≥ 0.45 (18.3% versus 42.5%, P = .049). As the mFI increased from 0 to ≥ 0.45 there was a stepwise increase in risk of major complications (P < .001). Additionally, 6-month mortality rate was considerably lower when the mFI was 0 rather than ≥ 0.27 (4.2% versus 20.4%, P = .007). Multivariate analysis demonstrated an mFI ≥ 0.27 was significantly associated with an increased incidence of major complication (OR 2.80, 95% CI 1.46-5.35, P = .002), all complication (OR 2.93, 95% CI 1.70-15.11, P < .001), 6-month mortality (OR 7.39, 95% CI 2.55-21.43, P < .001) and surgical site infection (OR 4.43, 95% CI 1.71-11.51, P = .002). The American Society of Anesthesiologists' (ASA) index did not share a stepwise relationship with any outcome.

CONCLUSION

The mFI is significantly associated in a gradated fashion with increased morbidity and mortality. Patients with an mFI ≥ 0.27 are at greater risk of major complications, all-complications, 6-monthy mortality, and surgical site infection.

Usefulness of the Modified Frailty Index for Predicting Pneumonia Occurrence After Esophagectomy

Background

Esophagectomy is an invasive and complication-prone surgical procedure. Therefore, a tool that can predict the occurrence of postoperative complications may be useful for perioperative management. In this study, we investigated whether the modified frailty index (mFI) could be a useful tool for predicting the postoperative complications of esophagectomy.

Methods

In this study, 162 patients who underwent curative esophagectomy for esophageal squamous cell carcinoma from 2004 to 2019 at our institution were included. The patients were divided into the high mFI (≥ 0.27) and low mFI (< 0.27) groups, and the short-term postoperative outcomes of each group were examined retrospectively.

Results

Regarding background factors, age and the American Society of Anesthesiologists physical status classification were significantly higher in the high mFI group (P = 0.049 and P = 0.002, respectively); however, the other items were not significantly different between the two groups. Regarding surgical outcomes, no significant differences in operative time, blood loss, and hospital stay were observed between the two groups. Regarding postoperative complications, pneumonia was significantly more common in the high mFI group (P = 0.035). In multivariate analysis, high mFI (P = 0.034) was an independent predictor of pneumonia, along with operative time ≥ 613 min (P = 0.03) and preoperative BMI < 20.48 (P = 0.006).

Conclusion

The mFI is useful for predicting pneumonia after esophagectomy.

Modified Frailty Index and Brief Geriatric Assessment does not predict prolonged hospitalization in elderly patients undergoing appendectomy due to Acute Appendicitis

INTRODUCTION

Epidemiology and the outcomes of acute appendicitis in elderly people are very different from the younger patients. Aim of this study was to investigate the significance of frailty syndrome in the course of acute appendicitis.

METHODS

All patients over 65 years old who underwent laparoscopic appendectomy between 2013 and 2021 in 2nd Department of General Surgery were included in the study. In our assessment Modified Frailty Index and Brief Geriatric Assessment were performed.

RESULTS

In the analyzed period 106 appendectomies were performed in patients over 65 years old. Postoperative complications occurred in 13 patients (12.3%). Prolonged hospitalization (over 3 days) was observed in 48 patients (45.3%). Multivariate analysis showed that every ASA class (OR=2.406; 95% CI 1.089-5.316; p=0.030) and postoperative complication (OR=5.692; 95% CI 1.077-30.073; p=0.041) are risk factors for prolonged hospitalization. Our study identified diabetes (OR=5.956; 95% CI 1.391-25.510; p=0.016) as a risk factor for postoperative complications.

CONCLUSIONS

According to our study Modified Frailty Index and Brief Geriatric Assessment does not correlate with prolonged hospitalization or higher risk for postoperative complication after appendectomy in elderly people.

A Prospective Study Correlating Preoperative Modified Frailty Index With One-Year Mortality in the Elderly With Hip Fractures

Background Hip fractures occur frequently in the elderly population over the age of 60 years following low-energy domestic falls. The postoperative mortality after hip fracture surgery depends on numerous factors like comorbidities, pre-fall ambulatory status, nutritional status, cognition, and overall physical health. In this context, the physiological age and reserve play a vital role in mortality after hip fracture surgeries. This physiological reserve is measured in terms of "frailty." There are many frailty indices that assess the physiological reserves of an elderly patient. The modified frailty index (MFI) is one of the validated indexes predicting postoperative complications and mortality. So we concluded there is a need to assess the patients with MFI preoperatively, based on which mortality and postoperative complications could be predicted in our patients. Materials and methods We included 100 patients aged more than 60 years with intertrochanteric and neck of the femur fractures, who were managed surgically. We followed the patients for one year and observed the immediate and late complications and mortality at the end of one year. To reduce bias, patients with pathological fractures, revision surgeries, contralateral fractures, high-energy trauma, younger than 60 years of age, and previous proximal femur fracture surgery on the side of injury were excluded from the study. Results The primary objective was to study the correlation between the MFI with one-year mortality. We observe that the MFI score had a significant effect on mortality at one year (p-value = 0.0316). With a unit increase in the MFI score, the odds of death increase by a factor of 1.52. Conclusion There is a strong correlation between MFI with one-year mortality and postoperative complications after hip fracture surgeries in the elderly. This MFI can be used as a preoperative predictive model to predict the mortality and postoperative complications after hip fractures in the elderly. It will also help patients and their caretakers in decision-making and elucidating surgery choices.

The Prognostic and Discriminatory Utility of the Clinical Frailty Scale and Modified Frailty Index Compared to Age

Background: There is no consensus on the optimal method for the assessment of frailty. We compared the prognostic utility of two approaches (modified Frailty Index [mFI], Clinical Frailty Scale [CFS]) in older adults (≥65 years) hospitalised with COVID-19 versus age. Methods: We used a test and validation cohort that enrolled participants hospitalised with COVID-19 between 27 February and 30 June 2020. Multivariable mixed-effects logistic modelling was undertaken, with 28-day mortality as the primary outcome. Nested models were compared between a base model, age and frailty assessments using likelihood ratio testing (LRT) and an area under the receiver operating curves (AUROC). Results: The primary cohort enrolled 998 participants from 13 centres. The median age was 80 (range:65−101), 453 (45%) were female, and 377 (37.8%) died within 28 days. The sample was replicated in a validation cohort of two additional centres (n = 672) with similar characteristics. In the primary cohort, both mFI and CFS were associated with mortality in the base models. There was improved precision when fitting CFS to the base model +mFI (LRT = 25.87, p < 0.001); however, there was no improvement when fitting mFI to the base model +CFS (LRT = 1.99, p = 0.16). AUROC suggested increased discrimination when fitting CFS compared to age (p = 0.02) and age +mFI (p = 0.03). In contrast, the mFI offered no improved discrimination in any comparison (p > 0.05). Similar findings were seen in the validation cohort. Conclusions: These observations suggest the CFS has superior prognostic value to mFI in predicting mortality following COVID-19. Our data do not support the use of the mFI as a tool to aid clinical decision-making and prognosis.

Defining ICD-10 surrogate variables to estimate the modified frailty index: a Delphi-based approach

BACKGROUND

There are currently no validated globally and freely available tools to estimate the modified frailty index (mFI). The widely available and non-proprietary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding could be used as a surrogate for the mFI. We aimed to establish an appropriate set of the ICD-10 codes for comorbidities to be used to estimate the eleven-variable mFI.

METHODS

A three-stage, web-based, Delphi consensus-building process among a panel of intensivists and geriatricians using iterative rounds of an online survey, was conducted between March and July 2021. The consensus was set a priori at 75% overall agreement. Additionally, we assessed if survey responses differed between intensivists and geriatricians. Finally, we ascertained the level of agreement.

RESULTS

A total of 21 clinicians participated in all 3 Delphi surveys. Most (86%, 18/21) had more than 5-years' experience as specialists. The agreement proportionately increased with every Delphi survey. After the third survey, the panel had reached 75% consensus in 87.5% (112/128) of ICD-10 codes. The initially included 128 ICD-10 variables were narrowed down to 54 at the end of the 3 surveys. The inter-rater agreements between intensivists and geriatricians were moderate for surveys 1 and 3 (κ = 0.728, κ = 0.780) respectively, and strong for survey 2 (κ = 0.811).

CONCLUSIONS

This quantitative Delphi survey of a panel of experienced intensivists and geriatricians achieved consensus for appropriate ICD-10 codes to estimate the mFI. Future studies should focus on validating the mFI estimated from these ICD-10 codes.

TRIAL REGISTRATION

Not applicable.

Modified Frailty Index Independently Predicts Postoperative Pulmonary Infection in Elderly Patients Undergoing Radical Gastrectomy for Gastric Cancer

Background

Pulmonary infection is one of the most common postoperative complications after radical gastrectomy for gastric cancer (GC) and is associated with a poorer prognosis. This study aimed to investigate potential predictive factors for pulmonary infection in elderly GC patients.

Methods

This study retrospectively enrolled 346 elderly GC patients undergoing elective radical gastrectomy between January 2017 and December 2020. Pulmonary infection within postoperative 30 days was set as the primary observational endpoint. The baseline demographic, clinicopathological, and laboratory data were compared between patients with or without pulmonary infection. ROC curves were plotted to evaluate the cut-off and predictive values of factors. Binary univariate and multivariate logistic regression analyses were employed to determine risk factors for postoperative pulmonary infection.

Results

Of the enrolled 346 patients, pulmonary infection was observed in 51 patients within postoperative 30 days, with an incidence of 14.7%. mFI was a significant predictor for pulmonary infection by ROC curve analysis (AUC: 0.770, P < 0.001). Moreover, preoperative mFI was the only independent risk factor for pulmonary infection (OR: 2.72, 95% CI: 2.02–3.31, P = 0.011) by univariate and multivariate logistic regression analyses.

Conclusion

Our study indicates that mFI independently predicts pulmonary infection in elderly GC patients.

Correlation of Sarcopenia With Modified Frailty Index as a Predictor of Outcome in Critically Ill Elderly Patients: A Cross-Sectional Study

INTRODUCTION

Frailty phenotype represents weight loss, decreased functional and physical capacity and activity, falls, slow gait, and memory impairment. Sarcopenia is a generalized and progressive loss of skeletal muscle mass, strength, and function, which occurs due to primary effects of aging and secondary effects of other causes including diseases, malnutrition, and inactivity.

MATERIALS AND METHODS

This prospective cross-sectional study was performed on 70 critically ill geriatric patients (of age > 60 years) admitted in Medicine ICU (MICU) from December 2020 to May 2021 at a rural medical school at Wardha in central rural India. We assessed sarcopenia in all the patients by the European Working Group on Sarcopenia in Older People (EWGSOP) criteria and compared it with the modified frailty index. All the patients were divided in sarcopenic and non-sarcopenic groups; frailty index was applied, and outcomes were measured in terms of mortality, the need for ventilation, and length of ICU stay.

RESULTS

In this study, the mean age of the patients was 68.61 ± 5.88 years in the sarcopenic group and 69.10 ± 6.31 years in the non-sarcopenic group. Eighteen (42.86%) patients in the sarcopenic group were severely frail, whereas eight (28.57%) patients in the non-sarcopenic group (p = 0.532) were not. In the sarcopenic severely frail group, mortality was six (14.29%), and eight (19.05%) required ventilation (p = 0.001), whereas in the non-sarcopenic severely frail group, mortality as well as the need for ventilation were four (14.29%) (p = 0.0001). Total duration of ICU stays was 4.30 ± 1.07 days in the sarcopenic group (n = 42), whereas it was 3.85 ± 1.23 days in the non-sarcopenic group (n = 28) (p = 0.10).

CONCLUSION

Our study found that critically ill patients with sarcopenia had more tendency to become frail, thereby increased risk of mortality. A timely routine assessment for sarcopenia upon ICU admission may provide an important prognostic factor in patient outcomes.

Fatal outcome and intensive care unit admission after total hip and knee arthroplasty: An analytic of preoperative frailty and comorbidities

BACKGROUND

With increasing demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA), a higher percentage of patients are identified with comorbidities that might increase the risk of complications. We aimed to elucidate the preoperative characteristics of patients with a fatal outcome or admission to the Intensive Care Unit (ICU) within 90 days after THA or TKA. We arbitrarily hypothesized that more than 50% of those patients would be frail.

METHODS

This is a register based, explorative study including patients undergoing elective, unilateral, primary THA or TKA in the Capital Region of Denmark from 2010 to 2017, and who subsequently died or were admitted to the ICU within 90 days. The modified Frailty Index (mFI) was calculated from the medical records, and a score of ≥0.36 defined frailty.

RESULTS

A total of 33,758 patients underwent THA or TKA, and 284 patients (0.8%) died or were admitted to the ICU within 90 days. Fifty-seven patients (20%) were frail (95% CI 16.2-25.7%). The most common comorbidities were hypertension (63%) and pulmonary diseases (32%), and 56% used walking aids. Two or more comorbidities were present in 65% of patients, and 14% had no comorbidities at all.

CONCLUSION

Only 20% of patients with a fatal outcome or ICU admission after elective THA or TKA could be categorized as frail based on the mFI. Further studies with a prospective design are needed to clarify the mFI as a risk stratification tool in elderly multimorbid patients undergoing elective arthroplasty surgery.

The impact of frailty on patient-reported outcomes after elective thoracolumbar degenerative spine surgery

OBJECTIVE

Frailty has been shown to be a risk factor of perioperative adverse events (AEs) in patients undergoing various types of spine surgery. However, the relationship between frailty and patient-reported outcomes (PROs) remains unclear. The primary objective of this study was to determine the impact of frailty on PROs of patients who underwent surgery for thoracolumbar degenerative conditions. The secondary objective was to determine the associations among frailty, baseline PROs, and perioperative AEs.

METHODS

This was a retrospective study of a prospective cohort of patients older than 55 years who underwent surgery between 2012 and 2018. Data and PROs (collected with EQ-5D, Physical Component Summary [PCS] and Mental Component Summary [MCS] of SF-12, Oswestry Disability Index [ODI], and numeric rating scales [NRS] for back pain and leg pain) of patients treated at a single academic center were extracted from the Canadian Spine Outcomes and Research Network registry. Frailty was calculated using the modified frailty index (mFI), and patients were classified as frail, prefrail, and nonfrail. A generalized estimating equation (GEE) regression model was used to assess the association between baseline frailty status and PRO measures at 3 and 12 months.

RESULTS

In total, 293 patients with a mean ± SD age of 67 ± 7 years were included. Of these, 22% (n = 65) were frail, 59% (n = 172) were prefrail, and 19% (n = 56) were nonfrail. At baseline, the three frailty groups had similar PROs, except PCS (p = 0.003) and ODI (p = 0.02) were worse in the frail group. A greater proportion of frail patients experienced major AEs than nonfrail patients (p < 0.0001). However, despite the increased incidence of AEs, there was no association between frailty and postoperative PROs (scores on EQ-5D, PCS and MCS, ODI, and back-pain and leg-pain NRS) at 3 and 12 months (p ≥ 0.05). In general, PROs improved at 3 and 12 months (with most patients reaching the minimum clinically important difference for all PROs).

CONCLUSIONS

Although frailty predicted postoperative AEs, mFI did not predict PROs of patients older than 55 years with degenerative thoracolumbar spine after spine surgery.

The modified frailty index and patient outcomes following transforaminal lumbar interbody fusion surgery for single-level degenerative spine disease

OBJECTIVE

The modified frailty index (mFI) is a simple tool that measures physiological reserve based on a thorough history and physical examination. Its use has been validated in several surgical specialties, including spinal deformity surgery. Prior research has suggested no significant differences in clinical outcomes between elderly and nonelderly patients undergoing posterior lumbar interbody fusion. The authors sought to investigate the use of the mFI in patients undergoing transforaminal lumbar interbody fusion (TLIF) and the relationship between frailty scores and clinical outcomes.

METHODS

A retrospective chart review was conducted on 198 patients who underwent a single-level TLIF over a 60-month period at a single institution. For all patients, an mFI score was computed incorporating a set of 11 clinical factors to assess preexisting comorbidities and functional status. Clinical follow-up and health-related quality-of-life (HRQOL) scores were obtained at baseline and regular intervals of 6 weeks, 6 months, and 1 year following surgery.

RESULTS

Patients were grouped according to their level of frailty: no frailty (mFI = 0), mild frailty (mFI = 0.09), moderate frailty (mFI = 0.18), and severe frailty (mFI ≥ 0.27). One-way ANOVA revealed increasing levels of frailty to be associated with an increased rate of complications, from 10.3% to 63.6%. In addition, increasing levels of frailty were associated with longer hospital length of stay (LOS), from 3.1 days to 6.5 days, and lower rates of disposition to home. At the 1-year follow-up, increased levels of frailty were associated with worse HRQOL measures.

CONCLUSIONS

Increasing mFI score was associated with higher morbidity, longer inpatient LOS, and a lower probability of discharge to home in patients undergoing single-level TLIF. Consideration of the mFI may help surgeons improve decision-making across the spectrum of patients who are at risk from frailty.

Modified Frailty Index Independently Predicts Postoperative Delirium and Delayed Neurocognitive Recovery After Elective Total Joint Arthroplasty

BACKGROUND

Postoperative delirium (POD) and delayed neurocognitive recovery are 2 common subtypes of postoperative neurocognitive disorders that occur after total joint arthroplasty (TJA), associated with inferior surgical outcomes. The modified frailty index (mFI) reflects the status of physiologic decline and predicts adverse outcomes in various surgical patient cohorts. This study aims at examining the discriminatory value of the mFI to predict POD and delayed neurocognitive recovery after TJA.

METHODS

The study includes 383 participants admitted for primary elective TJA under general anesthesia combined with inhalation agents over the period from January 2018 to December 2019. POD and delayed neurocognitive recovery, based on the criteria provided by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), were assessed for each enrolled patient. A multivariate logistic regression analysis was performed to screen potential risk factors for POD and delayed neurocognitive recovery.

RESULTS

The total incidence of POD and the delayed neurocognitive recovery of this cohort were 17.2% (66/383) and 24.8% (95/383), respectively. Our data from the multivariate logistic regression analysis indicated that a higher age (≥72 years) and a higher mFI level (≥0.18) were 2 independent risk factors for both POD and delayed neurocognitive recovery in elderly subjects after TJA.

CONCLUSION

The mFI may be a promising predictor for both POD and delayed neurocognitive recovery in elderly subjects following TJA. Preoperative mFI evaluation can be used for risk stratification and offers significant potential in clinical application.

The 5-Factor Modified Frailty Index in the Geriatric Surgical Population

BACKGROUND

The modified frailty index (mFI-11) is a National Surgical Quality Improvement Program (NSQIP)-based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. In the past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 out of the original 11 factors remain. While the predictive power and usefulness of this 5-factor index (mFI-5) has been proven in previous work, it has yet to be studied in the geriatrics population. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission for patients aged 65 years and older.

METHODS

Spearman's Rho was calculated to compare the value, and unadjusted and adjusted logistic regressions were created for three outcomes in nine surgical subspecialties. Correlation coefficients were above .86 across all surgical specialties except for cardiac surgery. Adjusted and unadjusted models showed similar C-statistics for mFI-5 and 11.

RESULTS

Overall predictive values of geriatric mFI-5 and mFI-11 were lower than those for the general population but still had effective predictive value for mortality and post-operative complications (C-Stat ≥ .7) and weak predictive value for 30-day readmission.

CONCLUSIONS

The mFI-5 is an equally effective predictor as the mFI-11 in all subspecialties and an effective predictor of mortality and postoperative complication in the geriatric population. This index has credibility for future use to study frailty within NSQIP, within other databases, and for clinical assessment and use.

Enhanced Recovery After Surgery Protocols. Does Frailty Play a Role?

INTRODUCTION

The 5-modified frailty index (mFI) is a valid predictor of 30-day mortality after surgery. With the wide implementation of enhanced recovery after surgery (ERAS) protocols in colorectal patients, the predictive power of frailty and its contribution to morbidity and length of stay (LOS) can be underestimated.

METHODS

We reviewed all colectomy patients undergoing ERAS protocol at a single, tertiary care institution from January 2016-January 2019. The 5-mFI score was calculated based on the presence of 5 comorbidities: Congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease, functional status, and hypertension (HTN). Multivariate analysis was used to assess the impact of 5-mFI score on morbidity, emergency department (ED) visits, readmissions, and LOS.

RESULTS

360 patients were evaluated including 163 elderly patients. Frailer patients had a higher rate of ED visits (P = .024), readmissions (P = .029), and LOS (P < .001). Patients with CHF had a higher chance of prolonged LOS, whereas patients with HTN had a higher chance of ED. Elderly patients with an mFI score of 3 and 4 were likely to have longer LOS (P = .01, P = .07, respectively). Elderly patients with an mFI score of 4 were 15 times more likely to visit ED and 22 times more likely to be readmitted than patients with an mFI score of 0.

DISCUSSION

An increase in 5-mFI for elderly patients undergoing colorectal procedures increases ED visits or readmissions, and it correlates to a higher LOS, especially in elderly patients. This instrument should be used in the assessment of frail, elderly patients undergoing colorectal procedures.

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

Background

Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty’s ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH.

Methods

Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints.

Results

Of the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis.

Conclusion

While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.

A comparison of frailty indices in predicting length of inpatient stay and discharge destination following angiogram-negative subarachnoid hemorrhage

BACKGROUND AND PURPOSE

While patients with angiogram-negative subarachnoid hemorrhages (ANSAH) have better prognoses than those with aneurysmal SAH, frailty's impact on outcomes in ANSAH is unclear. We previously showed that the modified frailty index (mFI-11) is associated with poor outcomes following ANSAH. Here, we compared the mFI-5, mFI-11, Charlson Comorbidity Index (CCI), and temporalis thickness (TMT) to determine which index was the best predictor of ANSAH outcomes and mortality rates.

METHODS

In this retrospective cohort analysis between 2014 and 2018, patients with non-traumatic, angiogram negative SAH (ANSAH) were identified. The admission mFI-5, mFI-11, CCI, and TMT were calculated for each patient. Primary outcomes were mortality rate, discharge location, and prolonged length of stay (PLOS; LOS >85^th percentile). Multivariate logistic regression and receiver operating characteristic (ROC) curves were used to evaluate frailty as predictors of primary endpoints.

RESULTS

We included 75 patients with a mean age of 55.4 ± 1.5 years. There were 4 patient deaths (5.3%), 53 patients (70.7%) discharged home, and 11 patients (14.7%) with PLOS. On ROC analysis, the mFI-5 had the highest discriminatory value for mortality (AUC = 0.97) while the mFI-11 was most discriminatory for discharge home (AUC = 0.85) and PLOS (AUC = 0.78). On multivariate analysis, the only independent predictor of mortality was the mFI-11 (OR = 0.46; 95%CI: 1.45-14.23; p = 0.009) while the mFI-5 was the best predictor of discharge home (OR = 0.21; 95% CI: 0.08-0.61; p = 0.004). On multivariate analysis, the only independent predictor of PLOS was the Hunt and Hess score (OR = 2.63; 95%CI: 1.38-5.00; p = 0.003). The CCI and TMT were inferior to either mFI for predicting primary endpoints.

CONCLUSIONS

Increasing frailty is associated with poorer outcomes and higher mortality following ANSAH. The mFI-5 and mFI-11 were found to be superior predictors of discharge home and mortality rate. While larger prospective study is needed, frailty, as measured by mFI-11 and -5, should be considered when evaluating ANSAH prognosis.

Modified frailty index is an effective risk-stratification tool for patients undergoing total shoulder arthroplasty

BACKGROUND

Frailty, as quantified by the modified frailty index (mFI), has emerged as a promising method to identify patients at high risk of complications after surgery. Several studies have shown that frailty, as opposed to age, is more predictive of adverse surgical outcomes. We hypothesized that a 5-item mFI could be used to identify patients at elevated risk of complications after total shoulder arthroplasty (TSA).

METHODS

We identified patients aged 50 years or older who underwent TSA in the American College of Surgeons National Surgical Quality Improvement Program database. Pearson χ² analysis and linear regression were used to determine the association of the mFI score with 30-day postoperative complications, reoperation, readmission, length of stay (LOS), adverse hospital discharge, and mortality rate.

RESULTS

The study included 9861 patients with a mean age of 70 years. As the mFI score increased from 0 to 2 or greater, the following rates increased: postoperative complications from 4.2% to 9.4%, readmission from 1.6% to 4.4%, adverse hospital discharge from 6.3% to 19.6%, and LOS from 1.88 days to 2.43 days (P < .001). Multivariate analysis showed that patients with an mFI score of 2 or greater were over twice as likely to sustain a postoperative complication (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.86-3.10), readmission (OR, 2.80; 95% CI, 1.88-4.17), reoperation (OR, 1.82; 95% CI, 1.02-3.25), and adverse hospital discharge (OR, 3.14; 95% CI, 2.51-3.92). These effects were all significantly higher compared with age.

CONCLUSION

Frailty is associated with increased rates of 30-day postoperative complications, readmission, reoperation, adverse hospital discharge, and hospital LOS after TSA. Use of a simple frailty evaluation may help inform decision making and risk assessment when considering TSA.

Assessing Frailty and Its Implications on Anesthesia Care and Postoperative Outcomes in Surgical Patients

Identification of elderly patients at high risk of poor outcomes following surgery remains difficult. Clinicians currently lack a tool to consistently aid them in this process. For instance, the ASA physical status score (ASA-PS) is one commonly used tool to identify high-risk surgical patients using comorbidities. However, this scoring system is too subjective to yield consistent results. According to retrospective research, the concept of frailty is a valid construct with the potential to create a generalizable method for improving poor healthcare outcomes by risk stratification. Research has shown frail patients have higher rates of morbidity, mortality, and postoperative complications. This article aims to explore the Phenotype Theory of Frailty and the Accumulated Deficits Theory of Frailty and possible anesthetic implications of incorporating frailty screening into patient care. Use of a modified frailty index as a tool in a high-quality preoperative evaluation may help practitioners risk-stratify patients. This can allow for earlier mobilization of care resources before surgery to improve outcomes.

Modified Frailty Index Is an Effective Risk Assessment Tool in Primary Total Knee Arthroplasty

BACKGROUND

"Frailty" is a marker of physiological decline of multiple organ systems, and the frailty index identifies patients who are more susceptible to postoperative complications. The purpose of this study is to validate the modified frailty index (MFI) as a predictor of postoperative complications, reoperations, and readmissions in patients who underwent primary total knee arthroplasty (TKA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2014 was queried by the Current Procedural Terminology code for primary TKA (27447). A previously described MFI was used to summate 11 variables in 5 organ systems. Bivariate analysis was performed for postoperative complications. A multiple logistic regression model was used to determine the relationship between MFI, American Society of Anesthesiologists score, and 30-day reoperation, controlling for age, gender, and body mass index.

RESULTS

A total of 90,260 patients underwent primary TKA during the study period. As MFI score increased, 30-day mortality significantly increased (P < .001). In addition, significantly higher rates of postoperative complications (all P < .001) were observed with increasing MFI: infection, wound, cardiac, pulmonary, and renal complications; and any occurrence. More frail patients also had increasing odds of adverse hospital discharge disposition, reoperation, and readmission (all P < .001). Length of hospital stay increased from 3.10 to 5.16 days (P < .001), while length of intensive care unit stay increased from 3.47 to 5.07 days (P < .001) between MFI score 0 and ≥0.36. MFI predicts 30-day reoperation with an adjusted odds ratio of 3.32 (95% confidence interval, 1.36-8.11; P < .001). Comparatively, MFI was a stronger predictor of reoperation compared with American Society of Anesthesiologists score and age with adjustment for gender and body mass index.

CONCLUSION

Utilization of the MFI is a valid method in predicting postoperative complications, reoperations, and readmissions in patients undergoing primary TKA and can provide an effective and robust risk assessment tool to appropriately counsel patients and aid in preoperative optimization.

Association of the modified frailty index with adverse outcomes after penile prosthesis implantation

OBJECTIVES

To investigate frailty as a predictor of surgical outcome in elderly patients undergoing penile prosthesis implantation.

MATERIAL AND METHODS

A total of 54 elderly patients, above 60 years of age, underwent penile prosthesis implantation between 2012 and 2014. Their data were collected and retrospectively analyzed. A modified frailty index (mFI) was calculated for each patient based on 11 risk factors from the Canadian Study of Health and Aging Frailty Index. The 1-year adverse outcomes were correlated with mFI, patients' and procedure's risk factors.

RESULTS

Mean age was 64.9 ± 5.2 years. No mortality was reported in our patients, however, one-year adverse outcomes were encountered in 43 (79.6%) patients. Among all studied variables, the 1-year adverse outcomes was not significantly association with mFI, but with preoperative glycosylated hemoglobin A1c (HbA1c) (p = 0.031) and associated Peyronie's disease (PD) (p = 0.000). HbA1c, dyslipidemia, hypertension, PD and duration of the procedure were predictive of infection complications (p < 0.05). Only PD and HbA1c sustained an independent significant impact.

CONCLUSIONS

mFI is not a predictive of post-penile prosthesis implantation adverse outcomes in elderly patients with impotence. Degree of diabetic control and association with PD was associated with the 1-year adverse outcomes and infection complications.

Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients

BACKGROUND AND OBJECTIVES

Frailty disproportionately impacts older patients with gastrointestinal cancer, rendering them at increased risk for poor outcomes. A frailty index may aid in preoperative risk stratification. We hypothesized that high modified frailty index (mFI) scores are associated with adverse outcomes after tumor resection in older, gastrointestinal cancer patients.

METHODS

Patients (60-90 years old) who underwent gastrointestinal tumor resection were identified in the 2005-2012 NSQIP Participant Use File. mFI was defined by 11 previously described, preoperative variables. Frailty was defined by an mFI score >0.27. The postoperative course was evaluated using univariate and multivariate analysis.

RESULTS

41 455 patients (mean age 72.4 years, 47.4% female) were identified. The most prevalent form of cancer was colorectal (69.3%, n = 28 708) and 2.8% of patients were frail (n = 1,164). Frail patients were significantly more likely to have increased length of stay (11.7 vs 9.0 days), major complications (29.1% vs 17.9%), and 30-day mortality (5.6% vs 2.5%), (all P < 0.001). Multivariate analysis identified mFI as an independent predictor of major complications (OR 1.52, 95%CI 1.39-1.65, P < 0.001) and 30-day mortality (OR 1.48, 95%CI 1.24-1.75, P < 0.001).

CONCLUSIONS

mFI was associated with the incidence of postoperative complications and mortality in older surgical patients with gastrointestinal cancer.

Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery

OBJECTIVE Limited tools exist to stratify perioperative risk in patients undergoing spinal procedures. The modified frailty index (mFI) based on the Canadian Study of Health and Aging Frailty Index (CSHA-FI), constructed from standard demographic variables, has been applied to various other surgical populations for risk stratification. The authors hypothesized that it would be predictive of postoperative morbidity and mortality in patients undergoing spine surgery. METHODS The 2006-2010 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing spine surgeries based on Current Procedural Terminology (CPT) codes. Sixteen preoperative clinical NSQIP variables were matched to 11 CSHA-FI variables (changes in daily activities, gastrointestinal problems, respiratory problems, clouding or delirium, hypertension, coronary artery and peripheral vascular disease, congestive heart failure, and so on). The outcomes assessed were 30-day occurrences of adverse events. These were then summarized in groups: any infection, wound-related complication, Clavien IV complications (life-threatening, requiring ICU admission), and mortality. RESULTS A total of 18,294 patients were identified. In 8.1% of patients with an mFI of 0 there was at least one morbid complication, compared with 24.3% of patients with an mFI of ≥ 0.27 (p < 0.001). An mFI of 0 was associated with a mortality rate of 0.1%, compared with 2.3% for an mFI of ≥ 0.27 (p < 0.001). Patients with an mFI of 0 had a 1.7% rate of surgical site infections and a 0.8% rate of Clavien IV complications, whereas patients with an mFI of ≥ 0.27 had rates of 4.1% and 7.1% for surgical site infections and Clavien IV complications, respectively (p < 0.001 for both). Multivariate analysis showed that the preoperative mFI and American Society of Anesthesiologists classification of ≥ III had a significantly increased risk of leading to Clavien IV complications and death. CONCLUSIONS A higher mFI was associated with a higher risk of postoperative morbidity and mortality, providing an additional tool to improve perioperative risk stratification.