Study finds association of frailty with with postoperative mortality, even in low-stress procedures

Frailty is associated with postoperative mortality across all noncardiac surgical specialties, regardless of case mix, researchers found.

Consequently, Elizabeth L. George, MD, MSc, Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California, and colleagues suggested that preoperative frailty assessment should be implemented across all specialties.

In this national cohort study, published in JAMA Surgery, the authors examined the association between frailty and mortality at the specialty level by examining surgical procedures with different physiologic stress and surgical risk levels. They used data from nine noncardiac specialties ((general, gynecologic, neurologic, orthopedic, otolaryngologic, plastic, thoracic, urologic, and vascular surgery) in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (2,239,031 patients) and the Veterans Affairs Surgical Quality Improvement Program (426,578 patients) from January 2010 through December 2014.

The primary outcome was postoperative mortality at 30 days in both the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) and 180 days (VASQIP).

For purposes of the study, the authors used a frailty measure tool called the Risk Analysis Index, which preoperatively categorized patients as robust (Risk Analysis Index 20), normal (21-29), frail (30-39), or very frail (40).

In addition, the Operative Stress Score (OSS) was used to categorize surgeries according to the associated physiologic stress, with low-stress procedures scored as 1 or 2, moderate-stress procedures scored as 3, and high-stress procedures as 4 or 5. In the NSQIP data group plastic surgery and otolaryngology were categorized as low-intensity, orthopedic surgery, urology, and neurosurgery as moderate-intensity, and general surgery, gynecology, vascular surgery, and thoracic surgery as high-intensity. In the VASQIP data group orthopedic surgery and urology were categorized as low- instead of moderate-intensity, while general surgery was categorized as moderate- instead of high-intensity. In both groups, plastic surgery was the least intense surgery, while thoracic surgery was the most intense.

Using plastic surgery as an example of a low-intensity specialty, the authors showed that for plastic surgery in NSQIP, the odds of 30-day mortality in very frail patients (adjusted odds ratio [aOR], 27.99; 95% CI, 14.67-53.39) and frail patients (aOR, 5.1; 95% CI, 3.03- 8.58) were statistically significantly higher than for normal patients.

Using neurosurgery as an example of a moderate-intensity specialty, the authors observed an association between frailty and 30-day mortality for neurosurgery in very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail patients (aOR, 4.18; 95% CI, 3.58-4.89). The same association held true for vascular surgery as an example of a high-intensity specialty in very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail patients (aOR, 3.42; 95% CI, 3.19-3.67).

In the VASQIP group there was an association with 30-day mortality in:

  • Very frail (aOR, 14.15; 95% CI, 4.19-47.77) and frail patients (aOR, 3.68; 95% CI, 1.21-11.21) after plastic surgery.
  • Very frail (aOR, 32.1; 95% CI,20.95- 49.16) and frail patients (aOR, 5.22; 95% CI, 3.43-7.96) after neurosurgery.
  • Very frail (aOR, 12.66; 95% CI, 10.31-15.55) and frail patients (aOR, 4.23; 95% CI, 3.51-5.10) after vascular surgery.

The association between frailty and mortality persisted at 180 days for every specialty, the authors determined.

While frailty and OSS differed substantially across surgical specialties, “the patterns of mortality for frail and very frail patients were similar for low-, moderate-, and high-intensity specialties in NSQIP and VASQIP,” George and colleagues noted. “More specifically, very frail patients experienced greater than 10% 30-day mortality and 30% 180-day mortality after undergoing a low-stress procedure in all 3 specialty intensity categories.”

“This study supported the hypothesis that frailty is universally associated with survival outcomes across surgical specialties with varying case-mix, independent of operative stress and emergency status,” they concluded. “Thus, preoperative frailty assessment should be implemented for all specialties regardless of the planned procedure to facilitate risk stratification and shared decision-making.”

In a commentary accompanying the study, Devon Anderson, MD, and Elizabeth C. Wick, MD, both of the Department of Surgery, University of California, San Francisco, wrote that the “sound methods” of the study, as well as the number of subjects included, “reinforce that the association between frailty and postoperative mortality is real and not a reflection of a skewed data set.”

They added that the study emphasizes that even low-risk procedures can substantially increase mortality and morbidity in frail patients, suggesting that many factors not necessarily related to the stress levels of surgical procedures lead to unfavorable results.

“This critical point suggests that frailty assessments should be integrated into the preoperative assessment, decision-making, and planning before all surgeries, no matter how low the risk,” wrote Anderson and Wick.

  1. Frailty is associated with postoperative mortality regardless of the stress-level of the noncardiac surgery involved.

  2. According to this study, frailty assessments should be integrated into preoperative planning across all surgical specialties.

Michael Bassett, Contributing Writer, BreakingMED™

George reported receiving salary support from the Palo Alto Veterans Health Care system as part of a Veterans Affairs Center for Innovation to Implementation research fellowship during the conduct of the study.

Cat ID: 159

Topic ID: 97,159,791,192,925,159