Perioperative Complications Linked to Patient Frailty

Diana Phillips

October 16, 2017

Physical frailty, more than chronological age, is associated with an increased risk for complications after common ambulatory surgery in older adults, a study has shown.

A retrospective analysis of patient outcome data from a national surgical registry showed that general surgery patients older than 40 years with high scores on a validated frailty index had worse perioperative outcomes after "seemingly low-risk" ambulatory surgical procedures than those with lower frailty scores. The increased risk was independent of age, type of anesthesia, and other comorbidities.

Carolyn D. Seib, MD, from the Department of Surgery at the University of California, San Francisco, and colleagues report their findings in an article published online October 11 in JAMA Surgery. The researchers say the study results suggest clinicians should consider patient frailty during preoperative planning and decision making and adjust informed consent accordingly.

The researchers identified a cohort of 140,828 patients older than 40 years from the 2007 to 2010 American College of Surgeons National Surgical Quality Improvement Program registry who underwent ambulatory hernia, breast, thyroid, or parathyroid surgery. The authors measured frailty using the 11-item National Surgical Quality Improvement modified frailty index (mFI).

Low, intermediate, and high mFI scores corresponded to the number of frailty traits patients exhibited: low scores corresponded with 0 to 1 traits, intermediate scores with 2 to 3 traits, and high scores with 4 or more traits.

Of the full cohort, 118,831 patients had low mFI scores, 21,036 had intermediate mFI scores, and 961 had high mFI scores. The most common frailty traits in patients with intermediate or high mFI scores were hypertension, insulin- and noninsulin-dependent diabetes, and coronary artery disease.

The primary study outcomes were any type of 30-day complication (pneumonia, unplanned intubation, ventilator dependence, cardiac arrest or myocardial infarction, stroke or coma for longer than 24 hours, acute or progressive renal failure, bleeding, sepsis, surgical site infections, wound dehiscence, venous thromboembolism, and urinary tract infections) and serious 30-day complications, excluding urinary tract infections and superficial surgical site infections, that could significantly affect patients' quality of life, recovery, and long-term functional outcomes.

Although overall and serious complication rates were low (1.7% and 0.7%, respectively), "the relative risk of complications was increased, with patients with 2 to 3 frailty traits (intermediate mFI score) having more than 2 times the odds of serious complications, after adjusting for poor prognostic factors," the authors write. Specifically, after adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, the odds ratios (ORs) for any and serious complications, respectively, in patients with intermediate mFI scores were 1.70 (95% confidence interval [CI], 1.54 - 1.88; P < .001) and 2.00 (95% CI, 1.72 - 2.34; P < .001).

As mFI score increased, so did the risk for any and serious complications. For patients with high mFI scores, the respective ORs for any and serious complications rose to 3.35 (95% CI, 2.52 - 4.46; P < .001) and 3.95 (95% CI, 2.65 - 5.87; P < .001).

In the adjusted model, a significant association between age and serious complications emerged for patients aged 80 to 89 years (OR, 1.36; 95% CI, 1.04 - 1.77; P = .03) and those 90 years of age or older (OR, 2.27; 95% CI, 1.21 - 4.24; P = .01).

Consistent with findings from single-center studies, the current analysis showed that the only modifiable covariate associated with decreased odds of serious complications was anesthesia with local and monitored anesthesia care (OR, 0.66; 95% CI, 0.53 - 0.81; P < .001).

The findings add to a growing body of literature supporting the inclusion of preoperative frailty assessment surgical planning, including a recent study linking preoperative frailty screening to a reduced mortality in elderly patients reported by Medscape Medical News.

"The assessment of frailty in a geriatric patient can be relevant to both preoperative risk stratification and risk modification to improve outcomes," the authors write. "Therefore, our goal for frailty assessment in the preoperative setting should be to improve patient selection and the informed consent process for frail patients, regardless of chronological age, and to remove barriers to treatment for older nonfrail patients."

The study authors have disclosed no relevant financial relationships.

JAMA Surg. Published online October 11, 2017. Abstract

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