Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties

Abstract

IMPORTANCEFrailty is an important risk factor for postoperative mortality. Whether the association between frailty and mortality is consistent across all surgical specialties, especially those predominantly performing lower stress procedures, remains unknown.OBJECTIVE To examine the association between frailty and postoperative mortality across surgical specialties. DESIGN, SETTING, AND PARTICIPANTSA cohort study was conducted across 9 noncardiac specialties in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) from January 1, 2010, through December 31, 2014, using multivariable logistic regression to evaluate the association between frailty and postoperative mortality. Data analysis was conducted from September 15, 2019, to April 30, 2020. Patients 18 years or older undergoing noncardiac procedures were included.EXPOSURES Risk Analysis Index measuring preoperative frailty categorized patients as robust (Risk Analysis Index Յ20), normal (21-29), frail (30-39), or very frail (Ն40). Operative Stress Score (OSS) categorized procedures as low (1-2), moderate (3), and high (4-5) stress. Specialties were categorized by case-mix as predominantly low intensity (>75% OSS 1-2), moderate intensity (50%-75%), or high intensity (<50%).MAIN OUTCOMES AND MEASURES Thirty-day (both measures) and 180-day (VASQIP only) postoperative mortality. RESULTSOf the patients evaluated in NSQIP (n = 2 339 031), 1 309 795 were women (56.0%) and mean (SD) age was 56.49 (16.4) years. Of the patients evaluated in VASQIP (n = 426 578), 395 761 (92.78%) were men and mean (SD) age was 61.1 (12.9) years. Overall, 30-day mortality was 1.2% in NSQIP and 1.0% in VASQIP, and 180-day mortality in VASQIP was 3.4%. Frailty and OSS distributions differed substantially across the 9 specialties. Patterns of 30-day mortality for frail and very frail patients were similar in NSQIP and VASQIP for low-, moderate-, and high-intensity specialties. Frailty was a consistent, independent risk factor for 30-and 180-day mortality across all specialties. For example, in NSQIP, for plastic surgery, a low-intensity specialty, the odds of 30-day mortality in very frail (adjusted odds ratio [aOR], 27.99; 95% CI,) and frail (aOR, 5.1; 95% CI, 3.03-8.58) patients were statistically significantly higher than for normal patients. This was also true in neurosurgery, a moderate-intensity specialty, for very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail (aOR, 4.18; 95% CI, 3.58-4.89) patients and in vascular surgery, a high-intensity specialty, for very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail (aOR, 3.42; 95% CI, 3.19-3.67) patients. CONCLUSIONS AND RELEVANCEIn this study, frailty was associated with postoperative mortality across all noncardiac surgical specialties regardless of case-mix. Preoperative frailty assessment could be implemented across all specialties to facilitate risk stratification and shared decision-making.

Incidence of emergency neurosurgical TBI procedures: A population-based study

“…The incidence of emergency neurosurgery declined abruptly in patients above 85 years, which was somewhat unexpected since the incidence of TBI-related hospital admissions is highest for the eldest patients (21,34). Decisions to limit treatment are more often made for older patients (37,38), and for many of these patients, it is justi ed to refrain from emergency neurosurgery based on poor prognosis, severe comorbidity, and frailty (39,40). The use of age alone as a criterion for treatment limitation must be practiced with caution, since several studies have shown that older patients may bene t from aggressive treatment and access to rehabilitation (41)(42)(43)(44)(45)(46)(47).…”

Incorporating Outcomes that Matter to Older Adults into Surgical Research

“…Surgical specialties were categorized from low to high intensity, and the relationship between frailty and mortality held even for low‐intensity specialties such as plastic surgery 9 . In vascular surgery, a high‐intensity specialty, a designation of “very frail” as measured by the Risk Analysis Index was closely associated with 30‐day mortality (adjusted OR = 12.66, 95% CI = 10.31–15.55) 10 . Similarly, another recent study retrospectively evaluated 1,341 older adults undergoing three types of major surgery from the Health and Retirement Study.…”

“…9 In vascular surgery, a high-intensity specialty, a designation of "very frail" as measured by the Risk Analysis Index was closely associated with 30-day mortality (adjusted OR = 12.66, 95% CI = 10.31-15.55). 10 Similarly, another recent study retrospectively evaluated 1,341 older adults undergoing three types of major surgery from the Health and Retirement Study. The study objective was to evaluate the association between several geriatric conditions (functional dependence, cognitive impairment, and depression) and 1-year mortality.…”

Impact of Frailty On 5-Year Survival In Patients Older Than 70 Years Undergoing Colorectal Surgery for Cancer

“…On the other hand, the pre-operative detection of frailty is becoming more relevant in these older surgical patients. Frailty has been shown to be a good predictor of post-operative complications of major gastrointestinal procedures [3], and it has been associated with post-operative mortality across all noncardiac surgical specialties [4]. Additionally, frailty has a detrimental impact on costs and hospital pro t for elective surgery [5].…”