Editor's Note: Commentary based on George EL, Hall DE, Youk A, et al. Association between patient frailty and postoperative mortality across multiple noncardiac surgical specialties. JAMA Surg 2021;156:e205152.¹

Geriatric Cardiology Take Home Points

• In numerous studies, frailty has been associated with increased risk for perioperative complications, prolonged hospital stays, discharge to a skilled nursing facility, progressive functional decline, and death.
• Several tools are available for assessing frailty in the clinical setting, including the Fried Frailty Score, the Rockwood Frailty Index, and the Risk Analysis Index (RAI) used in this study. 
• The present study provides compelling evidence that patients undergoing a wide range of non-cardiac surgical procedures who are frail or very frail, as defined by the RAI, are at substantially increased risk for 30- and 180-day mortality relative to non-frail individuals.
• The impact of frailty on mortality is independent of traditional risk factors, implying that frailty assessment should be integrated into routine preoperative assessment of older individuals and select younger individuals, regardless of the type of surgery.
• Frailty assessment should also be used to inform pre-operative shared decision making in determining the potential risks and benefits of surgery in the context of the patient's individual healthcare goals and personal preferences. 

Rationale for Study: To identify the associations between frailty [using the Risk Analysis Index (RAI)], intensity of surgical specialty (low, moderate and high-intensity surgical specialty), and stress of surgery (using Operative Stress Score (OSS) to 30- and 90-day post-operative mortality.

Inclusion criteria: National Surgical Quality Improvement Program^® (NSQIP^®) and the Veterans Affairs Surgical Quality Improvement Program (VASQIP) records of patients >18 years of age who underwent noncardiac surgical procedures between January 1, 2010, and December 31, 2014, with available information on 30-day mortality for both and 180-day mortality for VASQIP.

Exclusion criteria: Missing data on variables necessary to calculate a RAI score; patients undergoing procedures not defined by the OSS; a procedure defined by a Current Procedural Terminology (CPT^®) code with less than 99 occurrences in the data set.

Funding: US Department of Veterans Affairs

Study Design:  Retrospective cohort study (N= 2,765,609) conducted over a period of 4 years.

Clinical Variables:

1. Noncardiac surgical specialties: general, gynecologic, neurologic, orthopedic, otolaryngologic, plastic, thoracic, urologic, and vascular surgery.
2. Frailty: assessed using the RAI, a validated tool for measuring frailty in surgical and nonsurgical populations based on the accumulation of deficits model of frailty. Robust (RAI ≤20), normal (21-29), frail (30-39), and very frail (≥40).
3. Operative stress score (OSS) categorized procedures according to physiological stress of surgery as low stress (OSS 1-2), moderate stress (OSS 3), and high stress (OSS 4-5).
4. Operative stress score
      Low intensity specialty: >75% low-stress cases
      Moderate intensity specialty: 50-75% low-stress cases
      High intensity specialty: <50% low-stress cases

Primary outcome(s): Postoperative mortality at 30 days (NSQIP^® and VASQIP) and 180 days (VASQIP)

Statistical analysis: Mean RAI was compared using one-way analysis of variance. 30- and 180-day mortality for the three specialty intensity categories were calculated after stratifying by frailty status and OSS. Multivariable logistic regression was done to evaluate the association between frailty and mortality (30 and 180 days), adjusting for the surgical stress of the procedure measured by the OSS and whether the procedure was classified as an emergency.

Results:
Overview
A total of 2,339,031 patients in NSQIP® and 426,578 patients in VASQIP met the inclusion criterion. Patients in NSQIP^® were younger as compared to VASQIP (mean [SD], 56.5 [16.4] vs. 61.1 [12.9] years; P<.001) with more sex parity compared with VASQIP (44.0% vs. 92.2% men, P<.001). VASQIP had a higher prevalence of frailty (frail, 8.4%; very frail, 2.1%) compared with NSQIP^® (frail, 5.3%; very frail, 0.8%) (P < .001). The distribution of frailty and OSS differed significantly across nine specialties in both NSQIP^® and VASQIP. Overall, 30-day mortality was 1.2% in NSQIP® and 1.0% in VASQIP, and 180-day mortality in VASQIP was 3.4%.

The 30-day mortality rate among very frail patients undergoing low stress procedures in low intensity subspecialties was 14.6% in NSQIP^® and 9.6% in VASQIP. Similarly, mortality rate among very frail patients in moderate and high intensity specialties was greater than 10% in both datasets. When stratified by OSS, 30- day mortality rates were greater than 10% following moderate stress procedures (OSS 3), and for the highest stress procedures (OSS 4-5), 30-day mortality rates were 5% to 10% in frail patients and 10% to 30% in very frail patients in both datasets, irrespective of the specialty intensity.

The 180-day mortality rates among very frail patients from VASQIP were greater than 25% regardless of OSS procedure and specialty intensity. Similarly, mortality rates in frail patients ranged from 15% to 18% mortality following OSS 3 procedures and 7% to 17% mortality after OSS 1-2 procedures. Non-frail patients had low 30-day mortality rates following low and moderate-stress procedures and less than 5% in high stress procedures across different specialties. Frail and very frail patients had higher odds of 30 and 180 mortality compared with non-frail patients across all specialties.

Subgroup analysis of different specialties also showed similar mortality rates. For plastic surgery, a low-intensity specialty, the odds of 30-day mortality in very frail (adjusted odds ratio [aOR], 27.99; 95% CI, 14.67-53.39) and frail (aOR, 5.1; 95% CI, 3.03-8.58) patients were statistically significantly higher than for non-frail patients. Similar results were seen in neurosurgery, a moderate-intensity specialty, for very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail (aOR, 4.18; 95% CI, 3.58-4.89) patients and in vascular surgery, a high-intensity specialty, for very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail (aOR, 3.42; 95% CI, 3.19-3.67) patients.

Limitations of study

• Unequal representation of all surgical specialties (across NSQIP^® and VASQIP) with discrepancies in what was considered as high and moderate intensity surgeries.
• Analysis not done at patient level.
• Majority of patients are male in VASQIP data.
• Cause of death not provided.
• Risk factors such as age, female sex, and certain comorbidities were not analyzed. This would facilitate targeting frailty assessments to those most likely to be frail and avoiding assessments in the large proportion that are robust. 
• Causality cannot be inferred (i.e., higher mortality in frail patients cannot be directly attributed to either frailty or to the surgical procedure).

Conclusion

• Frailty was a consistent, independent risk factor for 30- and 180-day mortality across all specialties irrespective of the surgery intensity.
• Preoperative objective frailty assessments should be considered for preoperative risk stratification regardless of the surgical specialty as clinically indicated.

References

1. George EL, Hall DE, Youk A, et al. Association between patient frailty and postoperative mortality across multiple noncardiac surgical specialties. JAMA Surg 2021;156:e205152.

Clinical Topics: Geriatric Cardiology, Prevention, Stress

Keywords: Geriatrics, Aged, Current Procedural Terminology, Frail Elderly, Odds Ratio, Length of Stay, Neurosurgery, Patient Discharge, Logistic Models, Prevalence, Skilled Nursing Facilities, Retrospective Studies, Quality Improvement, Parity, Veterans, Decision Making, Goals, Risk Assessment, Risk Factors, Postoperative Complications, Stress, Physiological, Analysis of Variance, Delivery of Health Care

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