Preoperative Frailty Increases Risk of Nonhome Discharge after Elective Vascular Surgery in Home-Dwelling Patients

Arya, Shipra; Long, Chandler A.; Brahmbhatt, Reshma; Shafii, Susan M.; Brewster, Luke P.; Veeraswamy, Ravi K.; Johnson, Theodore M.; Johanning, Jason M.

doi:10.1016/j.avsg.2016.01.052

Cited by 82 publications

(74 citation statements)

References 41 publications

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“…Frail home-dwelling patients undergoing elective vascular procedures are at high risk of not returning home after surgery. 39 However, even in the absence of frailty, discussions regarding postoperative discharge expectations are important, because overall, one in five elective OAR patients and one in 15 elective EVAR patients were discharged to locations other than home. In a study by Edgerton et al, 40 only half of the cardiac surgery patients discharged to an extended care facility returned to independent living, thus highlighting that discharge to a rehabilitation facility is not a "benign" event and can lead to prolonged or permanent stay away from home.…”

Section: Discussionmentioning

confidence: 99%

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

George

Chen

Trickey

et al. 2020

Journal of Vascular Surgery

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Objective: Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database. Methods:Patients undergoing elective open and endovascular AAA repair (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with $10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI $35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.Results: A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F ¼ 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001). Conclusions:There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair. (J Vasc Surg 2020;71:46-55.)

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Section: Discussionmentioning

confidence: 99%

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

George

Chen

Trickey

et al. 2020

Journal of Vascular Surgery

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“…Afecting disposition and, hence, patient wellness and health-care expenditure, frailty also increases the propensity of home-dwelling patients classiied as frail to be discharged to a facility other than their home after elective vascular interventions [86]. There is also evidence to support the idea that frail females are potentially at the highest risk of death after vascular surgery, suggesting that female gender may be an additive risk factor [87].…”

Section: Frailty and Peripheral Arterial Disease (Pad)mentioning

confidence: 74%

Frailty and Cardiovascular Disease

Chainani¹,

Riehl²,

Chainani³

et al. 2017

Frailty and Sarcopenia - Onset, Development and Clinical Challenges

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Cardiovascular disease (CVD) comprises a vast spectrum of disease states ranging from hypertension (HTN) to valvular heart disease (VHD). CVD is known to be the leading cause of morbidity, mortality, and health-care expenditure throughout the world. According to the World Health Organization, coronary artery disease (CAD) and stroke, both subsets of CVD, are the world's biggest killers, accounting for a combined 15 million deaths in 2015. These diseases have remained the leading causes of death globally in the last 15 years. In 2010, CAD alone was projected to cost the U.S. $108.9 billion including the cost of health-care services, medications, and lost productivity. The presence of frailty signiicantly worsens outcomes for patients sufering from CAD. With just this one example of how frailty afects CVD, it is clear that understanding the impact of frailty upon patients alicted with the spectrum of cardiovascular disease is integral for the care of this very signiicant patient population.

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“…Their initial validation included carotid patients. 28 Arya et al 16 similarly found that preoperative frailty (mFI > 0.25) was associated with a 2-fold increased risk of nonhome discharge after elective vascular surgical procedures including carotid surgery.…”

Section: Discussionmentioning

confidence: 98%

“…13 These scores have consistently been confirmed as independent risk factors for predicting adverse outcomes for surgical patients across a range of specialties including vascular surgery. 10,11,14-16 Both the modified frailty index (mFI), an 11-point index developed in the American College of Surgeon National Surgical Quality Improvement Program (NSQIP) database, and the Risk Analysis Index (RAI), a simplified version of the Porock 6-month mortality index, have been validated in CEA patients in these national data sets demonstrating that an increasing number of AD is associated with increased 30-day adverse events after CEA including stroke, mortality, and length of stay. 11,17,18 …”

Section: Introductionmentioning

confidence: 99%

An Accumulated Deficits Model Predicts Perioperative and Long-term Adverse Events after Carotid Endarterectomy

Sridharan¹,

Chaer²,

Wu³

et al. 2018

Annals of Vascular Surgery

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Background There is increasing recognition that decreased reserve in multiple organ systems, known as accumulated deficits (AD), may better stratify perioperative risk than traditional risk indices. We hypothesized that an AD model would predict both perioperative adverse events and long-term survival after carotid endarterectomy (CEA), particularly important in asymptomatic patients. Methods Consecutive patients undergoing CEA between 1st January 2000 and 31st December 2010 were retrospectively identified. Seven of the deficit items from the Canadian Study of Health and Aging–frailty index (coronary disease, renal insufficiency, pulmonary disease, peripheral vascular disease, heart failure, hypertension, and diabetes) were tabulated for each patient. Predictors of perioperative and long-term outcomes were evaluated using regression analysis. Results About 1,782 CEAs in 1,496 patients (mean age: 71.3 ± 9.3 years, 56.3% male, 35.4% symptomatic) were included. The risk of major adverse events (stroke, death, or myocardial infarction) at 30 days for patients with ≤3 deficits was 2.53% vs. 8.81% for patients with ≥4 deficits (P < 0.001). For patients with ≥5 deficits, the risk was 15.18%. Each additional deficit increased the odds of a 30-day major adverse event and hospital stay >2 days by 1.64 (P < 0.001) and 1.15 (P < 0.001), respectively. In multivariate analysis, the presence of ≥4 deficits was more predictive of perioperative major adverse events (odds ratio [OR] = 3.62, P < 0.001) than symptomatology within 6 months (OR = 1.57, P = 0.08) or octogenarian status (OR = 2.00, P = 0.02). Kaplan-Meier analysis showed significantly decreased survival over time with accumulating deficits (P < 0.001). Patients with ≥4 deficits have a hazards ratio for death of 2.6 compared to patients with ≤3 deficits (P < 0.001). Overall survival is estimated at 79.5% (95% confidence interval [CI]: 0.77–0.82) at 5 years in patients with ≤3 deficits versus 52.4% (95% CI: 0.46–0.58) in patients with ≥4 deficits, respectively. In subgroup analysis of asymptomatic patients, 5-year survival for octogenarian male patients with ≥4 deficits was only 26.8%. For asymptomatic males aged 70–79 years with ≥4 deficits, 5-year survival was 59.9%. Conclusions An AD model is more predictive of perioperative adverse events after CEA than age or symptomatic status. This model remains predictive of long-term survival. In asymptomatic male octogenarians with 4 or more AD, 5-year survival is severely limited.

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Preoperative Frailty Increases Risk of Nonhome Discharge after Elective Vascular Surgery in Home-Dwelling Patients

Cited by 82 publications

References 41 publications

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

Frailty and Cardiovascular Disease

An Accumulated Deficits Model Predicts Perioperative and Long-term Adverse Events after Carotid Endarterectomy

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