Frailty Screening May Cut Mortality in Older Elective Surgery Patients

By Marilynn Larkin

NEW YORK (Reuters Health) - Implementing a frailty screening tool at a Veterans Affairs (VA) medical center was associated with reduced perioperative mortality, and its use might improve surgical outcomes more widely, researchers suggest.

"Recent data indicate that frailty is a more powerful predictor of increased perioperative mortality, morbidity, and cost than predictions based on age or comorbidity alone," Dr. Daniel Hall of the VA Pittsburgh Healthcare System and University of Pittsburgh and colleagues write in JAMA Surgery, online November 30.

To investigate the potential of a frailty screening initiative, the team compared outcomes of patients operated on before and after mandatory implementation of their Risk Analysis Index (RAI). The 14-item RAI takes less than two minutes to complete in a nonfrail patient, generates scores ranging from 0 to 81, and has been shown to predict postoperative mortality (https://bit.ly/2gbfMJb)

Altogether, they had data on 9,153 patients (average age, 60) in the VA Pittsburgh Healthcare System who presented for major, elective, noncardiac surgery from 2007 to 2014.

Routine preoperative frailty assessments for elective surgery started in 2011. As part of the initiative, records of patients who scored 21 or higher on the RAI were flagged for review prior to surgery. Clinicians from surgery, anesthesia, critical care and palliative care were alerted to the patient's frailty and associated risks, after which perioperative plans were modified, if indicated, based on the multidisciplinary team's input.

Dr. Hall told Reuters Health by email, "After implementing the frailty screening initiative, we observed a three-fold increase in long-term survival at six and 12 months - even after controlling for age, frailty, and predicted mortality."

Specifically, overall 30-day mortality fell from 1.6% (84 of 5,275 patients) to 0.7% (26 of 3,878 patients, P<0.001) after the screening initiative became mandatory for elective surgery. Frail patients showed the greatest improvement, from 12.2% (24 of 197 patients) down to 3.8% (16 of 424; P<0.001). However, mortality rates also decreased among nonfrail patients, from 1.2% (60 of 5,078) to 0.3% (10 of 3,454; P<0.001).

The magnitude of improvement among frail patients increased at three months, from 23.9% (47 deaths among 197 patients) to 7.7% (30 of 389; P<0.001) and at one year, from 34.5% (68 of 197 patients) to 11.7% (36 of 309 patients; P<0.001).

"This study reports what we believe to be the first-ever demonstration that it is not only feasible to screen all elective-surgery patients for frailty, but that it is possible to act on that information to improve outcomes," Dr. Hall said.

"The precise mechanisms of the improvement are not clear and likely are multifactorial, given the complex behavioral modification induced by the intervention," he acknowledged. "However, these data provide preliminary proof of concept, and other VA and private hospitals are currently implementing similar strategies that will hopefully replicate the findings and improve the quality of perioperative care for some of the highest risk patients we serve."

Dr. Emily Finlayson of the University of California, San Francisco, coauthor of an accompanying editorial, told Reuters Health, "Although frailty reduces an individual's ability to recover from the stress of surgery, few surgeons assess a patient's frailty before considering surgery . . . Without giving many details about what was done with the information about frailty, the investigators observed a reduction in short- and long-term mortality."

"Frailty screening is actionable," she said by email, "and that action can take many forms, depending on the situation and goals of the patient: (1) informing the patient and family that the surgery will be high risk and to expect complications, and encouraging advanced care planning before surgery; (2) deciding that surgery is too high risk and deciding to pursue other treatment options (medical treatment, symptom management alone); and (3) making efforts to decrease frailty before surgery with prehabilitation, including nutritional supplementation, exercise, and smoking and alcohol cessation, and increasing social/community support."

Dr. Michael Russo, a general surgeon at MemorialCare Center for Obesity at Orange Coast Memorial Medical Center in Fountain Valley in California, told Reuters Health, "This may represent an additional tool like the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) online risk calculator, which helps surgeons and medical doctors more accurately predict short- and long-term outcomes after surgery."

"It is important to leverage these types of systems in medical practice," he said by email. "These tools allow us . . . to accurately assess the risks and benefits prior to moving forward with elective operations."

"Performing an elective operation on someone with a high frailty index may actually be of less benefit and greater risk than not operating at all," he concluded.

SOURCE: https://bit.ly/2h70oxm and https://bit.ly/2hk0ga2

JAMA Surg 2016.

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