Frailty Screening May Improve Outcomes for Older Surgical Patients

The utilization of a novel preoperative frailty screening system reduced mortality up to 365 days postsurgery and may serve as an easily implementable tool for assessing older surgical patients, according to research published in JAMA Surgery.

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Although many patients aged older than 65 years successfully undergo surgical interventions, operations can result in adverse outcomes, diminished quality of life, and mortality in others.

“Thus, there is an imperative to identify patients at greatest risk for harm, ensure their decision-making process regarding surgery is patient centered, and provide tailored clinical care to improve surgical outcomes in high-risk patients,” wrote Daniel E Hall, MD, MDiv, MHSc, assistant professor of surgery at University of Pittsburgh Medical Center and core investigator at the VA Center for Health Equity Research and Promotion (Pittsburgh, PA), and colleagues.

Prior research has identified frailty as a key indicator of perioperative mortality, complications, and increased postsurgical health care utilization. As such, the Veterans Affairs Nebraska-Western Iowa Health Care System (Omaha, NE) developed and implemented the Frailty Screening Initiative (FSI) to determine frailty levels of older patients seeking elective surgery. Dr Hall and colleagues sought to determine whether the FSI improved postsurgical outcomes in a cohort of 9153 patients who underwent major noncardiac surgery before (n = 5275) or after (n = 3878) its application.

The FSI utilized the Risk Analysis Index (RAI), a 14-question scoring system predictive for postsurgical mortality. Patients with an RAI score of 21 or greater were considered frail; these patients received an administrative review by the chief of surgery and other hospital personnel prior to their operations. Although the treatment teams could potentially use FSI outcomes to alter perioperative plans, frailty scores were not used to refuse patients’ surgeries they wanted to pursue. 

A total of 621 patients had an RAI score of 21 or greater, representing 6.8% of the overall cohort. The majority of patients were not considered frail, with 82.8% (n = 7576) having an FSI score between 0 and 10.

The researchers observed an overall decrease in 30-day mortality following the implementation of the FSI, from 1.6% (n = 84) preimplementation to 0.7% (n = 26) postimplementation (P < .001), with significant improvements seen in both frail patients (12.2% vs 3.8%; P < .001) and robust patients (1.2% vs 0.3%; P < .001).

Frail patients experienced better outcomes following FSI implementation at both 180 days (preimplementation vs postimplementation, 23.9% vs 7.7%; P < .001) and 365 days (34.5% vs 11.7%; P < .001) postsurgery. Although frailty remained associated with increased mortality risks, these risks were significantly reduced with the FSI’s implementation (P < .001). A multivariate analysis showed that the addition of FSI implementation correlated with improved postsurgical survival at 180 days and 365 days (P < .001 for both), after controlling for age, frailty, and predicted mortality.

Study limitations included the inability to include data from patients who elected not to undergo surgery following frailty screening, which may have contributed to selection bias; the reliance on data from a single institution; and the lack of quality-of-life data from surviving patients.

“Hospitals and surgeons are looking for replicable models that can efficiently use existing resources and improve the quality and safety of surgery in a rapidly aging population,” wrote Dr Hall and colleagues. “This study builds a platform for further investigation into the causal connections and mechanisms behind improved survival after systematic frailty screenings in preoperative populations. The sustainability of FSI in the long term and implementation in different settings will depend on implementation with clinical workflow, use of electronic medical records, and standardization of intervention for frail patients.” – Cameron Kelsall