Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases

Abstract

OBJECTIVE Frailty—the state defined by decreased physiological reserve and increased vulnerability to physiological stress—is exceedingly common in oncology patients. Given the palliative nature of spine metastasis surgery, it is imperative that patients be healthy enough to tolerate the physical insult of surgery. In the present study, the authors compared the association of two frailty metrics and the widely used Charlson Comorbidity Index (CCI) with postoperative morbidity in spine metastasis patients. METHODS A retrospective cohort of patients who underwent operations for spinal metastases at a comprehensive cancer center were identified. Data on patient demographic characteristics, disease state, medical comorbidities, operative details, and postoperative outcomes were collected. Frailty was measured with the modified 5-item frailty index (mFI-5) and metastatic spinal tumor frailty index (MSTFI). Outcomes of interest were length of stay (LOS) greater than the 75th percentile of the cohort, nonroutine discharge, and the occurrence of ≥ 1 postoperative complication. RESULTS In total, 322 patients were included (mean age 59.5 ± 12 years; 56.9% of patients were male). The mean ± SD LOS was 11.2 ± 9.9 days, 44.5% of patients had nonroutine discharge, and 24.0% experienced ≥ 1 postoperative complication. On multivariable analysis, increased frailty on mFI-5 and MSTFI was independently predictive of all three outcomes: prolonged LOS (OR 1.67 per point, 95% CI 1.06–2.63, p = 0.03; and OR 1.63 per point, 95% CI 1.29–2.05, p < 0.01, respectively), nonroutine discharge (OR 2.65 per point, 95% CI 1.74–4.04, p < 0.01; and OR 1.69 per point, 95% CI 1.36–2.11, p < 0.01), and ≥ 1 complication (OR 1.95 per point, 95% CI 1.23–3.09, p = 0.01; and OR 1.41 per point, 95% CI 1.12–1.77, p < 0.01). CCI was found to be independently predictive of only the occurrence of ≥ 1 postoperative complication (OR 1.45 per point, 95% CI 1.22–1.72, p < 0.01). CONCLUSIONS Frailty measured with either mFI-5 or MSTFI scores was a more robust independent predictor of adverse postoperative outcomes than the more widely used CCI. Both mFI-5 and MSTFI were significantly associated with prolonged LOS, higher complication rates, and nonroutine discharge. Further investigation in a prospective multicenter cohort is merited.

Association of Frailty Risk with Hospital Outcomes after Surgical Resection for Benign and Malignant Spinal Meningiomas

“…24 Additionally, in a retrospective single-institution cohort study of 322 patients undergoing surgery for spinal metastases from 2013 to 2020, Hersh et al demonstrated that 72.8% of patients had mFI-5 scores ≥ 1 and that 80.6% had MSTFI scores ≥ 1, corresponding to some degree of frailty risk. 27 Similarly, in a retrospective database cohort study of 4,583 patients undergoing surgery for spine metastases from 2002 to 2011, De la Garza Ramos et al found that 40.1% of patients had mild MSTFI-de ned frailty risk (MSTFI = 1), 24.7% of patients had moderate frailty risk (MSTFI = 2), and 18.0% of patients had severe frailty risk (MSTFI ≥ 3). 29 The prevalence of increased HFRS in patients undergoing spinal tumor surgeries has also been assessed.…”

“…29 Additionally, in the study of 322 patients undergoing surgery for spinal metastases, Hersh et al showed that higher mFI-5-de ned-and MSTFI-de ned frailty risks were each signi cantly associated with prolonged LOS and non-routine discharges on multivariate analysis. 27 Furthermore, in a retrospective Nationwide Readmissions Database (NRD) study of 1,974 patients with increased frailty risk and 1,975 controls undergoing surgery for spinal metastases from 2016 to 2017, Bakhsheshian et al demonstrated that increased frailty risk was signi cantly associated with prolonged LOS (OR: 7.54) and non-routine discharge (OR: 3.86) on multivariate analysis. 36 Moreover, in a retrospective single-institution study of 350 adult patients undergoing surgery for vertebral column tumors, Ehresman et al found that higher mFI-5-de ned frailty risk was a signi cant predictor of non-routine discharge.…”

“…In the Hersh et al study of 322 patients undergoing surgery for spinal metastases, the authors found that higher MSTFI and Charlson Comorbidity Index (CCI) scores were signi cantly associated with experiencing ≥ 1 postoperative complication. 27 Additionally, in the retrospective study of 4,583 patients undergoing surgery for spinal metastases, De la Garza Ramos et al demonstrated that mild (OR: 1.88), moderate (OR: 3.83), and severe (OR: 6.97) MSTFI-de ned frailty risk had signi cantly greater odds of experiencing a postoperative complication. 29 Similarly, in a retrospective study of 1,589 patients undergoing surgery for primary spinal tumors from 2002 to 2011, Ahmed et al showed that patients with mild, moderate, and severe frailty risk each had signi cantly greater odds of experiencing postoperative complications.…”

“…[21][22][23] In patients with primary and metastatic spinal tumors, several metrics have been used to assess frailty risk, including the metastatic spinal tumor frailty index (MSTFI), the modi ed 5-item frailty index (mFI-5), and the modi ed 11-item frailty index (mFI-11). [24][25][26][27][28][29] However, prior studies have questioned the utility of these indices in predicting poor outcomes among patients undergoing spinal surgery. 24,30,31 A newer metric is the hospital frailty risk score (HFRS), developed using International Classi cation of Diseases, Tenth Revision (ICD-10) codes for medical conditions highly represented in a cohort of elderly patients.…”

Prospective application of the risk analysis index to measure preoperative frailty in spinal tumor surgery: A single center outcomes analysis

“…Frailty, a measure of baseline physiological reserve, is a powerful predictor of outcomes after surgical procedures. 5 , 6 , 7 , 8 , 9 , 10 Frail patients across the spectrum of surgical subspecialties have been shown to experience more postoperative complications, adverse discharge disposition, and increased mortality rates. 6 , 9 , 10 , 11 , 12 The Clinical Risk Analysis Index (RAI-C) questionnaire and scoring system is a quantitatively robust frailty measurement developed and validated by Hall et al to predict mortality in surgical populations derived from administrative databases and clinical settings.…”