Associations of Baseline Frailty Status and Age With Outcomes in Patients Undergoing Vestibular Schwannoma Resection

Abstract

IMPORTANCEAlthough numerous studies have evaluated the influence of advanced age on surgical outcomes following vestibular schwannoma (VS) resection, few if any large-scale investigations have assessed the comparative prognostic effects of age and frailty. As the population continues to age, it is imperative to further evaluate treatment and management strategies for older patients. OBJECTIVE To conduct a population-based evaluation of the independent associations of chronological age and frailty (physiological age) with outcomes following VS resection. DESIGN, SETTING, AND PARTICIPANTSIn this large-scale, multicenter, cross-sectional analysis, weighted discharge data from the National Inpatient Sample were searched to identify adult patients (Ն18 years old) who underwent VS resection from 2002 through 2017 using International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision, Clinical Modification codes. Data collection and analysis took place September to December 2020. MAIN OUTCOMES AND MEASURESComplex samples regression models and receiver operating characteristic curve analysis were used to evaluate the independent associations of frailty and age (along with demographic confounders) with complications and discharge disposition. Frailty was evaluated using the previously validated 11-point modified frailty index (mFI). RESULTS Among the 27 313 patients identified for VS resection, the mean (SEM) age was 50.4 (0.2) years, 15 031 (55.0%) were women, and 4720 (21.0%) were of non-White race/ethnicity, as determined by the National Inpatient Sample data source. Of the included patients, 15 090 (55.2%) were considered robust (mFI score = 0), 8204 (30.0%) were prefrail (mFI score = 1), 3022 (11.1%) were frail (mFI score = 2), and 996 (3.6%) were severely frail (mFI score Ն3). On univariable analysis, increasing frailty was associated with development of postoperative hemorrhagic or ischemic stroke (odds ratio [OR], 2.44 [95% CI, 2.07-2.87]; area under the curve, 0.73), while increasing age was not. Following multivariable analysis, increasing frailty and non-White race/ethnicity were independently associated with both mortality (adjusted OR [aOR], 2.32 [95% CI, 1.70-3.17], and aOR, 3.05 [95% CI, 1.02-9.12], respectively) and extended hospital stays (aOR, 1.54 [95% CI, and aOR, 1.71 [95% CI,.05], respectively), while increasing age was not. Increasing frailty (aOR, 0.61 [95% CI, 0.56-0.67]), age (aOR, 0.98 [95% CI, 0.97-0.99]), and non-White race/ethnicity (aOR, 0.62 [95% CI 0.51-0.75]) were all independently associated with routine discharge. CONCLUSIONS AND RELEVANCEIn this cross-sectional study, findings suggest that frailty may be more accurate for predicting outcomes and guiding treatment decisions than advanced patient age alone following VS resection.

Patient frailty association with cerebral arteriovenous malformation microsurgical outcomes and development of custom risk stratification score: an analysis of 16,721 nationwide admissions

“…These findings concur with prior neurosurgical studies that have correlated high frailty with medical complications. 8 However, these scores were less predictive of adverse surgical events, with only the CCI being associated with neurological complications and none predicting perioperative hemorrhage. Consequently, frailty status as denoted by these metrics may be a more accurate measure of risk assessment for postoperative recovery than for surgically related morbidity.…”

“…We calculated the high frailty threshold for each score by determining the point on its corresponding ROC curve at which Youden's index (sum of sensitivity and specificity) was maximized. 8 This threshold was ≥ 2 for all 3 frailty scores. Previous studies have validated the association between preoperative frailty and hospital disposition in the setting of neurosurgery, supporting the utility of hospital discharge status as a proxy for functional status and outcome for frailty stratification.…”

“…[3][4][5] Recent studies have demonstrated the clinical value of frailty-diminishing physiological reserve associated with comorbidity burden-as a predictor of morbidity and mortality across various skull base procedures. [6][7][8] However, this frailty-outcome relationship is poorly characterized for patients undergoing cerebrovascular surgery. This gap in understanding is critical because patients with neurovascular pathologies often have significant comorbidity profiles leading to postoperative complications like intracranial hemorrhage and reoperation.…”

“…9,10 Among hundreds of frailty and risk stratification measures documented in the literature, the 5-factor modified frailty index (mFI-5), 11-factor modified frailty index (mFI-11), and Charlson Comorbidity Index (CCI) have been assessed extensively across the neurosurgical literature. 8,[11][12][13] However, the use of these scores in the setting of cerebrovascular surgery has three limitations. First, it remains unclear which frailty score most accurately predicts patient outcomes following neurosurgery, as only the CCI has been studied in relation to microsurgical outcomes for aneurysm repair and arteriovenous malformation (AVM) resection.…”

“…17 Per the methodology of Dicpinigaitis et al, we determined functional health status in the NIS using codes corresponding to impairments in activities of daily living, bedridden status, and fall risk. 8 Receiver operating characteristic (ROC) curves were created for each frailty score with reference to their classification of discharge disposition to discriminate between low-frailty and highfrailty patients in the study population. We calculated the high frailty threshold for each score by determining the point on its corresponding ROC curve at which Youden's index (sum of sensitivity and specificity) was maximized.…”