Frailty Index associated with postoperative complications and mortality after lower extremity amputation in a national veteran cohort

Association between nutritional risk and fatigue in frailty conditions for older adult patients: a multicentre cross-sectional survey study

BACKGROUND AND AIMS

Frailty is widespread in the elderly, while there is a bi-directional relationship between frailty and malnutrition. The objectives of this study were to investigate the prevalence and correlation of frailty and nutritional risk in older adult patients and to analyse the factors associated with fatigue which is one indicator of frailty.

METHODS

This cross-sectional multicentre survey study was conducted in five hospitals in the same city from 01 January 2021 to 01 December 2021. We collected information on gender, age, diseases, medication and dietary status. Frailty status was diagnosed using the FRAIL scale, and Nutritional Risk Screening-2002 was used to screen the nutritional risk. Spearman rank correlation was used to analyse the correlation between frailty and nutritional risk. Univariate and multivariate logistic regression analyses were used to analyse the risk factors related to fatigue in all patients and inpatients.

RESULTS

Among 2016 older adult patients, the prevalence of frailty was 15.1% (305/2016), the prevalence of nutritional risk was 16.2% (327/2016) and the overlap prevalence of frailty and nutritional risk was 7.3% (147/2016). Multivariate analysis showed that nutritional risk (OR 3.109, 95% CI 2.384 to 4.056, p<0.001) was an independent risk factor for fatigue in all patients; similar results were found for nutritional risk (OR 2.717, 95% CI 2.068 to 3.571, p<0.001) in hospitalised patients.

CONCLUSIONS

Frailty and nutritional risk are prevalent among older adult patients, and nutritional risk is associated with the occurrence of fatigue in older adult patients and older adult inpatients.

TRIAL REGISTRATION NUMBER

China Clinical Trial Registry (Registered No. ChiCTR-EPC-14005253).

Preoperative Frailty Assessment Predicts Postoperative Mortality, Delirium and Pneumonia in Elderly Lung Cancer Patients: A Retrospective Cohort Study

BACKGROUND

The purpose of this study was to investigate the predictive value of the 5-factor modified frailty index (mFI-5) for postoperative mortality, delirium and pneumonia in patients over 65 years of age undergoing elective lung cancer surgery.

METHODS

Data were collected from a single-center retrospective cohort study conducted in a general tertiary hospital from January 2017 to August 2019. In total, the study included 1372 elderly patients aged over 65 who underwent elective lung cancer surgery. They were divided into frail group (mFI-5, 2-5), prefrail group (mFI-5, 1) and robust group (mFI-5, 0) on the basis of mFI-5 classification. The primary outcome was postoperative 1-year all-cause mortality. Secondary outcomes were postoperative pneumonia and postoperative delirium.

RESULTS

Frailty group had the highest incidence of postoperative delirium (frailty 31.2% versus prefrailty 1.6% versus robust 1.5%, p < 0.001), postoperative pneumonia (frailty 23.5% versus prefrailty 7.2% versus robust 7.7%, p < 0.001), and postoperative 1-year mortality (frailty 7.0% versus prefrailty 2.2% versus robust 1.9%. p < 0.001). Frail patients have significantly longer length of hospitalization than those in the robust group and prefrail patients (p < 0.001). Multivariate analysis showed a clear link between frailty and increased risk of postoperative delirium (aOR 2.775, 95% CI 1.776-5.417, p < 0.001), postoperative pneumonia (aOR 3.291, 95% CI 2.169-4.993, p < 0.001) and postoperative 1-year mortality (aOR 3.364, 95% CI, 1.516-7.464, p = 0.003).

CONCLUSIONS

mFI-5 has potential clinical utility in predicting postoperative death, delirium and pneumonia incidence in elderly patients undergoing radical lung cancer surgery. Frailty screening of patients (mFI-5) may provide benefits in risk stratification, targeted intervention efforts, and assist physicians in clinical decision-making.

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

Frailty score and outcomes of patients undergoing vascular surgery and amputation: A systematic review and meta-analysis

Introduction

Frailty is associated with adverse postoperative health outcomes, including increased mortality, longer length of stay, higher rehospitalization, and other complications. There are many frailty assessment tools are to assess the level of frailty in vascular surgery patients. The aim of this study was to perform a systematic review and meta-analysis to assess the association between the frailty levels described by different frailty scores and adverse postoperative health outcomes among hospitalized vascular surgery patients and patients undergoing amputation.

Methods

Studies utilizing frailty scores and similar frailty assessment tools to describe frailty and investigate the association between frailty and health outcomes were searched. The primary outcomes of this study were in-hospital mortality, postdischarge mortality, length of hospital stay, rehospitalization, and discharge location. Additional outcomes included postoperative myocardial infarction, postoperative renal failure, cerebrovascular accident and stroke, comorbidities, and estimated glomerular filtration rate (eGFR) levels. Joanna Briggs Institute (JBI) Critical Appraisal Tools were used for quality assessment.

Results

In total, 24 studies with 1,886,611 participants were included in the final analysis. The overall results found that higher in-hospital mortality and postdischarge mortality were significantly associated with frailty. Frailty was also found to be significantly associated with a longer length of hospital stay, higher rehospitalization, and higher likelihood of non-home discharge. In addition, the results also showed that frailty was significantly associated with all kinds of comorbidities investigated, except chronic kidney disease. However, lower eGFR levels were significantly associated with frailty.

Conclusion

Among patients who underwent all types of vascular surgery and those who underwent amputations, assessment of frailty was significantly associated with adverse postoperative outcomes and multiple comorbidities.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=336374, identifier CRD42022336374.

Frailty and outcomes following revascularization of lower-extremity peripheral artery disease: Insights from the Vascular Quality Initiative (VQI)

BACKGROUND

Multiple frailty screening tools are implemented; however, it is unclear whether they perform in a comparable way for both frailty detection and prediction of perioperative outcomes in patients undergoing lower-extremity revascularization.

METHODS

Patients undergoing lower-extremity revascularization were identified from the Vascular Quality Initiative (VQI) national database. Two cohorts were established based on the revascularization type (percutaneous vascular interventions (PVI) or lower-extremity bypass). Frailty was assessed by the 5-item modified frailty index (mFI-5) and the VQI-derived risk analysis index (RAI).

RESULTS

Out of 134,081 patients undergoing PVI, frailty was identified in 67% by mFI-5 and 28% by RAI. Similarly, out of 41,316 patients in the bypass cohort, frailty was identified in 69% by mFI-5 and 16% by RAI. There was little agreement between the two frailty tools for both vascular cohorts (PVI: kappa: 0.17; bypass: kappa: 0.13). In an adjusted analysis, frailty as assessed by mFI-5 and RAI was associated with higher odds of mortality in both cohorts (p < 0.001). A significant association between frailty and unplanned amputations was only noted in the bypass cohort when RAI was applied (OR: 1.50, p < 0.01). The addition of frailty to traditional PAD risk factors marginally improved model performance to predict mortality and unplanned major amputations.

CONCLUSION

There was significant variation in frailty detection by mFI-5 and RAI. Although frailty was associated with mortality, the predictive value of these tools in predicting outcomes in PAD was limited. Future research should focus on designing new frailty screening tools specific to the PAD population.

Elevated Risk Analysis Index (RAI) Frailty Scores Are Independently Associated with Adverse Outcomes in Lower Extremity Surgical Revascularizations Similarly Across Genders

INTRODUCTION

The Risk Analysis Index (RAI) frailty scoring system, developed in a predominantly male Veteran sample, has recently undergone revision and external validation to become the RAI-rev using a general surgical sample from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. We set forth to evaluate the application of RAI-rev scoring to lower extremity surgical revascularization outcomes in the NSQIP database while verifying that similar associations with outcomes persist in this subset across genders.

METHODS

All elective cases in the NSQIP Targeted Lower Extremity Open (LEO) database recorded from 2015-2019 were paired with the NSQIP Participant User File using Case IDs. Groups were defined by EMR-recorded gender. Extended length of stay was defined as top quartile postoperative stays. Aggregate demographics, perioperative factors, and 30-day outcomes were compared between groups using unpaired t-test and Fisher's exact test. Adjusted odds-ratios (aOR) for each outcome were generated by applying a multivariate binary logistic regression model in IBM SPSS^TM for five-point RAI-rev score increments from 25-45 and a most-frail group with scores >45. Covariates included surgical indication, prior ipsilateral surgical revascularization versus percutaneous intervention, graft utilization, presence of dirty/infected wound, smoking, hypertension, diabetes, and steroid use. A non-frail group with RAI-rev scores <25 was utilized as the reference for generating adjusted odds ratios.

RESULTS

8,155 cases were recorded in the NSQIP LEO database from 2015-2019, including 2,498 (31%) performed in women who had slightly lower RAI-rev scores on average (22.1±5.8 vs 24.2±5.1; p=0.0001). Univariate trends demonstrated dose-dependent increases in frequency of most outcomes with rising frailty score ranges, with the most substantial changes over mortality (0.4% of non-frail to 14.7% most-frail), disposition to a skilled nursing facility (8% of non-frail to 27% most-frail), and extended length of stay (16% of non-frail to 44% most-frail). After adjusting for co-variates, patients with RAI-rev scores of 26-30 had aOR of 1.4 (95% CI: 1.2-1.6; p<0.001), 1.9 (95% CI: 1.6-2.2; p<0.001), and 2.4 (95% CI: 1.3-4.4; p<0.001) for extended stay, disposition to skilled nursing, and mortality respectively as compared to those with RAI-rev scores <25. Despite more non-significant aOR for women than men, trends were similar across genders in both univariate and multivariate analyses.

CONCLUSION

Our study is the first to find that outcomes other than mortality are significantly predicted by RAI-rev score ranges in lower extremity surgical revascularizations with similar associations regardless of gender. RAI-rev frailty scores >30 may help to identify frail patients at a higher risk of mortality, extended stay, and increased rehabilitation needs prior to lower extremity surgical revascularization to inform risk assessment and optimize patient recovery.

Using the risk analysis index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair

OBJECTIVE

Surgical frailty is strongly associated with increased perioperative morbidity and mortality. The risk analysis index (RAI) is a validated frailty score system, which has been shown to predict for short-term outcomes and long-term mortality in various surgical subspecialties. In the present study, we applied the frailty score to a veteran aneurysm population who had undergone nonemergent endovascular aortic aneurysm repair (EVAR).

METHODS

After obtaining institutional review board approval, the Veteran Affairs Surgical Quality Improvement Program data were queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection using the Current Procedural Terminology codes 34,800, 34,803, and 34,805 from 2001 to 2018. The preoperative variables were used to calculate the RAI score. The patients were placed into six cohorts according to the RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). The χ² test and analysis of variance test were used compare the cohorts. Forward logistic regression modeling was used to determine the risks of each cohort.

RESULTS

From 2001 to 2018, 5568 patients had undergone EVAR. Of the 5568 patients, 99.6% were male, with a mean age of 71 ± 8 years. Of these patients, 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% were included in the following RAI groups: ≤20, 21 to 25, 26 to 30, 31 to 35, 35 to 40, and ≥41, respectively. Frailty was associated with increased rates of overall complications, death, and an increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated with 2.7 times the odds of any complication developing and 4.4 times the odds of mortality ≤30 days.

CONCLUSIONS

Frailty, as determined by the RAI, was associated with postoperative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean from ventilation, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients scheduled to undergo EVAR.