Frail Patients Who Are Connected To Resources Less Likely To Die One Year After Surgery - Mr Validity
Of 63,381 frail patients, 708 (1.1%) died after surgery. The thirty-day mortality rate in the lowest volume quintile was 1.1% compared to 0.9% in the highest. After adjustment for surgical risk, demographic characteristics, comorbidities, and clustering within hospitals, we found a significant association between frailty volume and improved survival (highest volume vs. lowest volume quintile: hazard ratio 0.51; 95% CI, 0.35 to 0.74; P
Frail patients who are connected to resources less likely to die one year after surgery - Mr Validity
Our exposure of interest was the number of frail patients cared for in the year before the index surgery at the index hospital. Frail patients were identified using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator, a frailty instrument designed for use in health administrative data. The ACG frailty-defining diagnoses indicator is a binary variable that uses 12 clusters of frailty-defining diagnoses (see Supplemental Digital Content section B, , for a table of conceptual clusters)31 and has been used to study frailty-related surgical outcomes28,32,33 and healthcare resource use.34,35 After elective surgery, patients identified as frail using the ACG frailty-defining diagnoses indicator have significantly decreased short-term33 and long-term28 survival, as well as consume a high level of healthcare resources.32 Because of the proprietary nature of the ACG system, specific diagnostic codes used are not available for dissemination. Frailty-defining diagnoses were identified from all healthcare encounters in our health administrative data in the 3 yr before the index hospital admission. While there is no definitive-standard frailty instrument,36 the concurrent validity of the ACG frailty-defining diagnoses indicator has been previously compared against the Vulnerable Elderly Scale, which was collected as part of a comprehensive geriatric assessment.37 Patients identified as frail using the ACG indicator had higher Vulnerable Elderly Scale scores than those without frailty-defining diagnoses (P
We identified 74,981 episodes of care at 81 distinct hospitals for patients with a preoperative frailty-defining diagnosis who had undergone an elective, intermediate- to high-risk noncardiac surgery; this represented 13% of all such surgeries in adults (fig. 1). Our analysis was limited to 63,381 frail patients having their first episode of care in a hospital that had cared for at least 10 frail surgical patients in the previous year. Patients were older and primarily female, with the majority of patients having an American Society of Anesthesiologists score of III or worse. Low, middle, and high frailty volume hospitals differed significantly by most patient characteristics (table 1).
Validated frailty assessments for primary care vary in the ease of administration, with more intensive options likely requiring allied healthcare staff beyond the physician to save cost and time. In comparison, rapid options may require the referral of patients in need of intensive screening through more thorough methodologies with a multidisciplinary team [42,43,44]. The International Conference on Frailty and Sarcopenia Research Consensus Guidelines recommend referral to a CGA after initial assessments identifying frailty given the low specificity often observed in frailty screening [44, 45]. A careful balance must be struck between the efficacy of the frailty approach used to identify interventional targets and the feasibility of utilizing the approach within resource constraints.
Frailty assessment has been proposed as a potential means of improving triage methods and identifying appropriate care for older patients in the ED/ICU [26, 71,72,73,74]. Given that patients with frailty are more likely to experience adverse outcomes, either through presenting illness or iatrogenic stress, care has to be adapted to meet the patient needs [75]. Recent systematic reviews have identified frailty as a predictor of in-hospital mortality, length of hospital stay, subsequent nursing home admission, and mortality in hospitalized older adults [76, 77]. Frailty assessment could assist with facilitating referrals to various health services and identifying optimal treatment options for that patient [69]. In severe illness, the additional iatrogenic stress of intensive care interventions needs to be considered in patients with advanced frailty [78]. Furthermore, frailty status affects the association between acuity of patient illness and mortality [79, 80]. For example, Pulok et al. found that high acuity illness was associated with significant mortality risk regardless of frailty status, but even those with low acuity illness were at risk for mortality when the degree of frailty was higher [79].
As in the ED/ICU setting, identifying patients at risk for adverse outcomes could be valuable in assessing the likelihood of benefit of surgical intervention and potentiates referrals to interventions aimed at increasing patient resilience prior to surgery [101,102,103]. If a patient with frailty is known to be less able to tolerate health stressors such as an invasive surgery, less invasive options or even non-surgical supportive therapy may better fit the goals of patient care. For example, surgical aortic valve replacement (SAVR) is the choice of intervention for many patients requiring valve replacement. The less invasive transcatheter aortic valve implantation (TAVI) is used in those at higher risk of surgical and post-surgical adverse events [104]. An assessment of frailty status could be used as a means of making the most informed choice for surgical intervention [104, 105] and could also guide perioperative care, such as tailoring the anaesthetic or other specific approaches to prevent delirium onset [73] of which frail individuals are at increased risk [106].
Amputation at any age is a significantly disabling event. However, when a geriatric patient undergoes a LEA, it can have devastating - even fatal - consequences. In a study by Fletcher, et al[1], the median survival was 1.5 years after an amputation, which is significantly less than the expected survival rate of 7.5 years for age-matched controls. There is a significant increase in 30 day mortality rate related to age and number of co-morbiditis[3]. It is estimated that approximately 13% of geriatric patients will die within 30 days of undergoing a LEA. If a geriatric patient has 4-5 co-morbidities, they are 7 times more likely to die within 30 days of amputation compared to patients with only one comorbidity.
Recent findings: Frailty is associated with increased complications, longer length of hospital stay and increased mortality after surgery. Frail kidney transplant patients have increased delayed graft function, mortality and early hospital readmission. Frail lung or liver transplant patients are more likely to delist or die on the waitlist. Prehabilitation can mitigate frailty and has resulted in decreased length of hospital stay and fewer postsurgical complications among a variety of surgical populations. Increasingly, WFTs are used to monitor patient activity and improve patient health. Interventions using WFTs have resulted in improved activity, weight loss and blood pressure.
Pre-operative impairment in ADLs and IADLs have been shown to be strong predictors of sustained post-operative functional impairment following major abdominal surgery in older adults,31 in addition to being important risk factors for post-operative geriatric syndromes (i.e., delirium, functional decline, falls and pressure ulcers).32 In the urologic literature, one study of 176 patients undergoing percutaneous nephrolithotomy (PCNL) demonstrated that pre-operative impairment in ADLs independently predicted post-operative complications, while ASA classification and Charlson comorbidity index did not.33 Another study of nursing home residents undergoing transurethral resection of the prostate (TURP) demonstrated increased risk of TURP failure (measured by the presence of a Foley catheter one year after surgery) and prolonged post-operative functional impairment up to one year following surgery in patients with impaired baseline functional status (as measured by ADLs).34
Elective urologic surgery should be delayed for 14 days after coronary balloon angioplasty, 30 days after bare metal stent (BMS) implantation, and one year after drug-eluting (DES) implantation.89 Elective urologic surgery may be considered after 180 days in patients with DES implantation if the risk of surgical delay is greater than the risk of cardiac ischemia and stent thrombosis. However, dual antiplatelet (AP) therapy should not be discontinued for elective urologic surgery in patients who had a BMS within 30 days or DES within one year.89 As newer DES and antiplatelet agents are developed and the optimal time between stent placement and elective surgery changes, consultation with internal medicine or cardiology is important.
Major surgery results in a profound systemic inflammatory response with a significant increase in body oxygen requirement during the post-operative period.137-141 Older or frail patients are less likely to have the physiologic reserve to compensate for the increased aerobic demands of major surgery. There is an inverse relationship between a patients' pre-operative aerobic capacity and poor surgical outcomes.142,143 Patients with poor cardiopulmonary conditioning prior to cystectomy, for example, are at greater risk for post-operative complications and prolonged lengths of stay.144 Importantly, aerobic capacity is trainable over a relatively short period before surgery. Previous work has demonstrated that a pre-operative exercise program as short as four weeks prior to pulmonary resection for lung cancer can lead to an increase in aerobic capacity of 21.5 percent.145 041b061a72