BACKGROUND: Risk stratification of epilepsy surgery patients remains difficult. The Risk Analysis Index (RAI) is a frailty measurement that augments preoperative risk stratification. OBJECTIVE: To evaluate RAI's discriminative threshold for nonhome discharge disposition (NHD) and mortality (or discharge to hospice within 30 days of operation) in epilepsy surgery patients. METHODS: Patients were queried from the American College of Surgeons-National Surgical Quality Improvement Program database (2012-2020) using diagnosis/procedure codes. Linear-by-linear trend tests assessed RAI's relationship with NHD and mortality. Discriminatory accuracy was assessed by C-statistics (95% CI) in receiver operating characteristic curve analysis. RESULTS: Epilepsy resections (N = 1236) were grouped into temporal lobe (60.4%, N = 747) and nontemporal lobe (39.6%, N = 489) procedures. Patients were stratified by RAI tier: 76.5% robust (RAI 0-20), 16.2% normal (RAI 21-30), 6.6% frail (RAI 31-40), and 0.8% severely frail (RAI 41 and above). The NHD rate was 18.0% (N = 222) and positively associated with increasing RAI tier: 12.5% robust, 34.0% normal, 38.3% frail, and 50.0% severely frail (P < .001). RAI had robust predictive discrimination for NHD in overall cohort (C-statistic 0.71), temporal lobe (C-statistic 0.70), and nontemporal lobe (C-statistic 0.71) cohorts. The mortality rate was 2.7% (N = 33) and significantly associated with RAI frailty: 1.1% robust, 8.0% normal, 6.2% frail, and 20.0% severely frail (P < .001). RAI had excellent predictive discrimination for mortality in overall cohort (C-statistic 0.78), temporal lobe (C-statistic 0.80), and nontemporal lobe (C-statistic 0.74) cohorts. CONCLUSION: The RAI frailty score predicts mortality and NHD after epilepsy surgery. This is accomplished with a user-friendly calculator: https://nsgyfrailtyoutcomeslab.shinyapps.io/epilepsy/.
<b><i>Introduction:</i></b> Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry. <b><i>Methods:</i></b> The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (<i>n</i> = 1,211), hemifacial spasm (<i>n</i> = 236), or glossopharyngeal neuralgia (<i>n</i> = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis. <b><i>Results:</i></b> Patients undergoing MVD (<i>N</i> = 1,473) were stratified by RAI frailty bins: 71% with RAI 0–20, 28% with RAI 21–30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, <i>p</i> = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, <i>p</i> = 0.001), and AD (6.1% vs. 1.0%, <i>p</i> < 0.001). The rate of primary endpoint was 2.4% (<i>N</i> = 36) and was positively associated with increasing frailty tier: 1.5% in 0–20, 5.8% in 21–30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74–0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61–0.66) (DeLong pairwise test, <i>p</i> = 0.003). <b><i>Conclusions:</i></b> This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: <ext-link ext-link-type="uri" xlink:href="https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression" xmlns:xlink="http://www.w3.org/1999/xlink">https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression</ext-link>.
Objective: The endoscopic spine surgery (ESS) approach is associated with high levels of patient satisfaction, shorter recovery time, and reduced complications. The present study reports multicenter, international data, comparing ESS and non-ESS approaches for singlelevel lumbar decompression, and proposes a frailty-driven predictive model for nonhome discharge (NHD) disposition.Methods: Cases of ESS and non-ESS lumbar spine decompression were queried from the American College of Surgeons National Surgical Quality Improvement Program database (2017–2020). Propensity score matching was performed on baseline characteristics frailty score (measured by risk analysis index [RAI] and modified frailty index-5 [mFI-5]). The primary outcome of interest was NHD disposition. A predictive model was built using logistic regression with RAI as the primary driver.Results: Single-level nonfusion spine lumbar decompression surgery was performed in 38,686 patients. Frailty, as measured by RAI, was a reliable predictor of NHD with excellent discriminatory accuracy in receiver operating characteristic (ROC) curve analysis: C-statistic: 0.80 (95% confidence interval [CI], 0.65–0.94) in ESS cohort, C-statistic: 0.75 (95% CI, 0.73–0.76) overall cohort. After propensity score matching, there was a reduction in total operative time (89 minutes vs. 103 minutes, p = 0.049) and hospital length of stay (LOS) (0.82 days vs. 1.37 days, p < 0.001) in patients treated endoscopically. In ROC curve analysis, the frailty-driven predictive model performed with excellent diagnostic accuracy for the primary outcome of NHD (C-statistic: 0.87; 95% CI, 0.85–0.88).Conclusion: After frailty-based propensity matching, ESS is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty-driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decisionmaking with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_dischargedispo.
Introduction: To evaluate the discriminative accuracy of the preoperative Risk Analysis Index (RAI) frailty score for prediction of mortality or transition to hospice within 30 days of brain tumor resection (BTR) in a large multi-center, international, prospective database. Methods: BTR patients were extracted from the American College of Surgeons-National Surgical Quality Improvement Program (2012-2020) database. The relationship between the RAI frailty scale and the primary endpoint (mortality or discharge to hospice within 30-days of surgery) were assessed by linear-by-linear proportional trend tests, logistic regression, and receiver operating characteristic curve (ROC) analysis (area under the curve as C-statistic). Results: Patients with BTR (N=31,776) were stratified by RAI frailty tier: 16,800 robust (52.8%), 7,646 normal (24.1%), 6,593 frail (20.7%), and 737 severely frail (2.3%). The mortality/hospice rate was 2.5% (n=803) and positively associated with increasing RAI tier: robust (0.9%), normal (3.3%), frail (4.6%), and severely frail (14.2%) (P<0.001). Isolated RAI was a robust discriminatory of primary endpoint in ROC analysis in the overall BTR cohort (C-statistic: 0.74, 95% CI: 0.72-0.76) as well as the malignant (C-statistic: 0.74, 95% CI: 0. 67-0.80) and benign tumor subsets (C-statistic: 0.71, 95% CI: 0.70-0.73) (all P<0.001). RAI score had statistically significantly better performance compared to mFI-5 and chronological age (both P<0.0001). Conclusions: RAI frailty score predicts 30-day mortality after BTR and may be translated to the bedside with a user-friendly calculator (https://nsgyfrailtyoutcomeslab.shinyapps.io/braintumormortalityRAIcalc/. The findings hope to augment the informed consent and surgical decision-making process in this patient population and provide an example for future study designs.
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