Preoperative Frailty Screening Initiative Reduces Mortality

Jennifer Garcia

December 02, 2016

Implementation of a Frailty Screening Initiative (FSI) appears to reduce postoperative mortality among elderly patients, according to a cohort study published online November 30 in JAMA Surgery.

"The absolute reduction in 180-day mortality among frail patients was more than 19%, with improvement remaining robust even after controlling for age, frailty, and predicted mortality," write Daniel E. Hall, MD, MDiv, MHSc, from the Veterans Affairs Pittsburgh Healthcare System, Pennsylvania, and colleagues.

The researchers evaluated data from 9153 patients undergoing elective, noncardiac surgical procedures between October 1, 2007, and July 1, 2014. The mean age of patients was 60.3 years, and the majority were male.

Development and testing of the Risk Analysis Index (RAI), which is a 14-point questionnaire, started in July 2010, and deployment at the hospital was started in January 2011, with full implementation in July 2011. The authors note that an RAI score was required during surgical scheduling, which led to a near 100% adherence for elective surgeries.

Patients were screened for frailty at intake, and 6.8% were deemed as frail (RAI score ≥ 21). The authors note that the proportion of patients deemed frail before and after implementation were similar, as were patient demographics and American Society of Anesthesiologists classification. After implementation of the frailty screening, changes to surgical planning and perioperative care were instituted as needed after review by clinicians from surgery, anesthesia, critical care, and palliative care.

The authors found that overall 30-day mortality decreased from 1.6% (84/5275) to 0.7% (26/3878) after FSI implementation (P < .001). Use of the FSI appeared to have the greatest effect on mortality rate among frail patients, going from 12.2% (24/197) to 3.8% (16/424; P < .001); however, mortality rates decreased among robust patients as well, going from 1.2% (60/5078) to 0.3% (10/3454; P < 0.001).

The researchers also noted improvements at 180 days postoperatively, going from 23.9% (47/197) to 7.7% (30/389; P < .001), and 365 days postoperatively, going from 34.5% (68/197) to 11.7% (36/309; P < .001).

"This study reveals the feasibility of facility-wide frailty screening in elective surgical populations," write Dr. Hall and colleagues. "It also suggests the potential to improve postoperative survival among the frail through systematic administrative screening, review, and optimization of perioperative plans."

In addition, the researchers used a multivariable model that controlled for age and RAI score and evaluated the interaction between FSI implementation and frailty. They noted that although the interaction was not a significant predictor of mortality at 30 days (P = .66), it did predict survival at 180 and 365 days (P = .02 and P = .01, respectively). The authors underscore that "[t]his finding also suggests that it takes more than 30 days to detect the effect of these interventions, further delineating the limitations of 30-day outcomes noted by others."

The study authors acknowledge that the Hawthorne effect may have played a role in why improvements were noted in both frail as well as robust patients, as poor operative candidates may have been excluded from undergoing surgery.

In an invited commentary, Anne M. Suskind, MD, and Emily Finlayson, MD, both from the University of California, San Francisco, acknowledge the increasing importance of frailty assessment in the preoperative setting, but caution that "[e]xcluding patients with limited life expectancy from surgical interventions that may improve symptom management out of fear of poor mortality statistics is a real concern."

The commentators note that preoperative planning should be undertaken with a focus "on the patient's individual goals of care, which may not always include surgery."

"At the very least, preoperative frailty assessment serves as a portal into the overall surgical fitness of an individual and leads the surgeon to consider the whole person in addition to the surgical problem at hand," conclude Dr. Suskind and Dr. Finlayson.

Dr Hall and colleagues report the development and initial validation of the RAI score in a separate article, published online November 23 in JAMA Surgery. The full RAI questionnaire is available as a supplement to that article.

Funding for this study was provided through a grant from the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development. The authors and commentators have disclosed no relevant financial relationships.

JAMA Surg. Published online November 30, 2016. Article abstract, Commentary extract

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