A systematic review of frailty assessment tools used in vascular surgery research

Long-term survival among older adults with frailty undergoing elective vascular surgery procedures

OBJECTIVE

The Vascular Quality Initiative Frailty Index (VQI-FI) was developed using seven variables captured in all VQI registries and combined with procedure risk to provide a simple mortality risk assessment tool for preoperative decision-making. This study was designed to validate the ability of the VQI-FI within a subgroup population for discriminating long-term mortality risk among Medicare beneficiaries undergoing common elective vascular procedures.

METHODS

The VISION VQI-Medicare linked database (2010-2019) was used to assess survival among Medicare beneficiaries undergoing elective vascular procedures from seven arterial VQI registries. After stratifying patients into three groups based on degree of frailty using VQI-FI (<0.26, non-frail; 0.26-0.50, mild frailty; >0.50, moderate to severe frailty), we analyzed 1-year and 5-year mortality with Kaplan-Meier method and Cox proportional hazard models.

RESULTS

We identified 109,400 patients who underwent an elective vascular procedure (34% carotid endarterectomy, 7% carotid artery stenting, 16% endovascular aortic repair, 2% open aortic repair, 3% thoracic endovascular aortic repair, 8% infrainguinal bypass surgery, 2% suprainguinal bypass surgery, and 28% peripheral vascular intervention), of which 13% were mildly frail and 2% were moderate to severely frail. Patients with mild and moderate to severe frailty were more likely to be of Black race or Hispanic ethnicity, non-ambulatory, and living at a nursing facility at the time of surgery when compared with non-frail patients (P < .0001 for all comparisons within both 1-year and 5-year follow-up cohorts). Mortality at 1 year and 5 years after surgery was significantly higher among mildly and moderate to severely frail patients as compared with non-frail patients. In risk-adjusted Cox regression models, there was a significant increase in 5-year mortality among mildly frail (hazard ratio, 2.7; P < .0001) and moderate to severely frail (hazard ratio, 5.9; P < .0001) patients relative to non-frail patients.

CONCLUSIONS

Long-term survival is poor among frail Medicare patients undergoing elective vascular procedures with up to six times higher mortality than non-frail patients. These results highlight the need to identify frail patients before surgery, address modifiable risk factors, and provide realistic expectations about long-term outcomes after elective vascular surgery.

Transitions of frailty after lower extremity interventions for chronic limb-threatening ischemia

BACKGROUND

Frailty is common among surgical patients and predicts poor surgical outcomes. This study aimed to analyze transitions in frailty state among patients undergoing lower extremity care for chronic limb-threatening ischemia (CLTI).

METHODS

Between 2018 and 2022, all patients undergoing a primary intervention for CLTI (endovascular intervention [EV], bypass [BYP], major amputation [AMP]) or wound care were analyzed. Frailty was assessed by Vascular Quality Initiative-derived Risk Analysis Index. Frailty was defined as a Vascular Quality Initiative-derived Risk Analysis Index score of ≥35. Transition in frailty state between preoperative and follow-up measurement at 1 month and 1 year were analyzed. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis. Amputation-free survival (survival without AMP) and freedom from major adverse limb events (above-ankle amputation of the index limb or major re-intervention (new BYP graft, jump/interposition graft revision) were evaluated.

RESULTS

We included 1859 patients (56% male; mean age, 65 ± 11 years) who underwent either EV (52%), a BYP (29%), AMP (13%), or wound care (6%). Amon them, 25% were considered frail on initial evaluation (28%, 16%, 32%, and 30% EV, BYP, AMP, and wound care, respectively). At 30 days, overall frailty increased to 34%: 13% of patients moved from nonfrail to frail (9%, 18%, 22%, and 5% for EV, BYP, AMP, and wound care, respectively), and 4% of patients moved from frail to nonfrail (6%, 2%, 1%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, overall frailty increased to 40%: an additional 13% of patients shifted from nonfrail to frail (15%, 6%, 23%, and 8% for EV, BYP, AMP, and wound care, respectively), and 5% of patients shifted from frail to nonfrail (4%, 8%, 2%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, frailty increased by 28% in EV, 16% for BYP, 32% in AMP, and 43% in wound care. Frailty at baseline, 30 days, and 1 year was associated with a high Charlson's Comorbidity Index. Shifting to a frail state postoperatively was associated with decreased survival and a lower amputation-free survival at 1 year.

CONCLUSIONS

After major interventions for CLTI at 1 year, 27% of patients shift from a nonfrail to a frail state, and 9% of patients shift from a frail to a nonfrail state with differences across modalities in comparison to wound care, where 13% of patients moved from a nonfrail to a frail state, and none shifted from a frail to a nonfrail state. Shifting to a frail state after intervention is associated with poor outcomes and should be considered when evaluating and intervention in a patient with CLTI.

Frailty scores impact the outcomes of urgent carotid interventions in acute stroke patients: A comprehensive analysis of risk and prognosis

BACKGROUND

Carotid artery disease is an important cause of ischemic strokes. Patient selection for urgent carotid interventions (ie, urgent carotid endarterectomy [uCEA] and urgent carotid artery stenting [uCAS]) performed within 2 weeks of an event during the index hospitalization is based primarily on a patient's overall health and risk profile. Identifying high-risk patients remains a challenge. Frailty, a decrease in function related to aging, has emerged as an important factor in the treatment of the elderly population. This study aimed to design a quantitative risk score based on frailty for patients undergoing uCEA and uCAS after an acute stroke.

METHODS

A total of 307 acute stroke patients treated with uCEA or uCAS were identified from a prospectively maintained database. Frailty scores were calculated using the Hospital Frailty Risk Index based on International Classificiation of Diseases, 10th edition, codes. Stroke-specific risk categories were created based on the incidence of stroke, death, and myocardial infarction (MI) associated with frailty scores. Primary end points included 30-day stroke, death, and MI, and the secondary end point was discharge modified Rankin scale (mRS). Statistical analyses were performed using SAS software.

RESULTS

The average age was 65.9 years; hypertension, a history of tobacco use, and hyperlipidemia were the most common comorbidities. The median Hospital Frailty Risk Score was 27; the majority of patients in this study were in the intermediate and high risk frailty groups (50.5% and 41.7%, respectively). uCAS patients had a higher median presenting National Institutes of Health Stroke Scale (NIHSS) (8 vs 2; P < .001) and shorter median time to intervention compared with uCEA patients (1 day vs 3 days; P ≤ .001). The 30-day composite stroke, death, and MI rate was 8.1%, with higher rates observed in patients with frailty scores of >30 (11.7%) and uCAS (12.2%). Hemorrhagic conversion and death were more common in uCAS patients. Functional independence (mRS 0-2) was observed in uCEA patients after minor stroke and in uCAS patients after minor or moderate stroke. Patients with high-risk frailty score (>30) presenting with a moderate stroke were more likely to be functionally dependent (mRS > 2) on discharge (67 vs 41.3%; P < .001).

CONCLUSIONS

Frailty is a valuable prognosticative tool for clinical outcomes in patients undergoing urgent carotid interventions after an acute stroke. Higher frailty scores were associated with increased stroke, death, and MI rates. Frailty also influenced functional dependence at discharge, particularly in patients with moderate stroke. These findings highlight the importance of considering frailty in the decision-making process for carotid interventions. Further research is needed to validate these findings and explore interventions to mitigate the impact of frailty on outcomes.

Frailty in stroke

Stroke is predominantly a condition of older age. So, it seems sensible that specialists working in stroke services should understand the primary clinical syndrome of ageing-frailty. Recent studies have highlighted the prevalence of frailty in stroke and its associated poor outcomes, yet frailty does not feature prominently in stroke research, practice or policy. Frailty-informed stroke care may differ from the interventional management that dominates contemporary practice. However, this is not therapeutic nihilism. A person-centred approach ensures that every care decision is appropriate and based on a shared understanding of the person's goals and likely prognosis. We present a primer on frailty in stroke, describing definition(s), epidemiology and prognostic implications. We discuss the challenges surrounding assessment and management of frailty in stroke units and offer practical guidance suitable for the stroke clinician.

Prediction of postoperative mortality in older surgical patients by clinical frailty scale: A systematic review and meta-analysis

AIMS

To systematically evaluate the predictive efficacy of clinical frailty scale (CFS) for postoperative mortality older surgical patients, and to evaluate the prevalence of frailty in the included studies.

DESIGN

A systematic review and meta-analysis of observational studies was conducted, utilizing the MOOSE guidelines for the evaluation of both. Quality assessment of the articles was also performed.

DATA SOURCES

The protocol was registered (CRD42023423552). Relevant English and Chinese language studies published until October 20th, 2023 were retrieved from PubMed, Web of Science, Embase, Medline, CINAHL,Cochrane, WAN FANG DATA, VIP Information, CNKI, and SinoMed databases.

REVIEW METHODS

Study were included in which frailty was measured by the CFS and postoperative mortality was reported for older surgery patients. A meta-analysis to predict postoperative mortality and frailty prevalence was performed using STATA 17.0 software.

RESULTS

Sixteen cohort studies were included (5,864 participants) from 1,513 records. All studies' Newcastle-Ottawa Scale (NOS) scores were above 6 points. It was found that the prevalence of surgical frailty in the older was 0.36(CI 0.20-0.52). Patients assessed as frail by the CFS were associated with higher all-cause mortality (OR:4.01; CI 2.59-6.23). Subgroup analysis shows that frailty was associated with1-month mortality (OR:3.85; CI 1.11-13.45) and 1-year mortality (OR:4.43; CI 2.18-8.99).

CONCLUSIONS

The prevalence of frailty is high in older surgical patients, and CFS can effectively predict the mortality of older surgical patients with frailty.

Perceptions, awareness, and implementation surrounding the assessment of frailty amongst vascular surgeons in Italy: Results from a nationwide cross-sectional survey

OBJECTIVES

We conducted this survey to gain insight into the real-life application and perceptions regarding the importance of peri-operative frailty assessment amongst vascular surgeons in Italy.

METHODS

Italian vascular surgeons were invited to participate in the survey using the list provided by the Italian Society for Vascular and Endovascular Surgery (1050 invited participants). A dedicated link to the survey was emailed through Google Forms, and reminders were automatically sent on a bi-weekly basis for a total of 8 weeks before stopping data collection.

RESULTS

The survey was completed by 225 respondents, thereby yielding an overall 21.5% response rate. While the vast majority of respondents stated they were aware of the meaning of frailty (93%) and agreed that its assessment was clinically relevant for patients undergoing vascular surgery (99%), only 44% of surveyed surgeons reported that they used a specific tool for peri-operative frailty assessment. However, most respondents indicated that routine evaluation of frailty was not performed at their institution (87%). The main limitations were identified as being the lack of confidence in choosing the best tool, followed by lack of awareness, lack of skilled operators, and lack of time.

CONCLUSIONS

Our study showed that whilst most vascular surgeons in Italy are aware of the importance of frailty in affecting surgical outcomes across various interventions in the elective and non-elective settings, there is poor implementation of formal frailty assessment.

Frailty Assessment in Vascular OUtpatients Review (FAVOUR) protocol: single-centre prospective cohort study comparing feasibility and prognostic value of commonly used frailty assessment tools

INTRODUCTION

Frailty has consistently demonstrated associations with poorer healthcare outcomes. Vascular guidelines have recognised the importance of frailty assessment. However, an abundance of frailty tools and a lack of prospective studies confirming suitability of routine frailty assessment in clinical practice has delayed the uptake of these guidelines. The Frailty Assessment in Vascular OUtpatients Review study speaks to this evidence gap. The primary aim is to assess feasibility of implementing routine frailty assessment in a reproducible outpatient setting. Secondary objectives include comparing prognostic values and interuser agreement across five frailty assessment tools.

METHODS AND ANALYSIS

This single-centre prospective cohort study of feasibility is conducted in a rapid-referral vascular surgery clinic, serving a population of 2 million. Adults with capacity (>18 years), attending a clinic for any reason, are eligible for inclusion. Five assessments are completed by patient (Rockwood Clinical Frailty Scale (CFS) and Frail NonDisabled Questionnaire), clinician (CFS, Healthcare Improvement Scotland FRAIL tool and 'Initial Clinical Evaluation') and researcher (11-item modified Frailty Index). Consistent with feasibility objectives, outcome measures include recruitment rates, frailty assessment completion rates, time-to-complete assessments and interuser variability. Electronic follow-up at 30 days and 1 year will assess home-time and mortality as prognostic indicators. Patients treated surgically/endovascularly will undergo additional 30-day and 1-year postoperative follow-up, outcome measures include: surgical procedure, mortality, complications (according to Clavien-Dindo Classification), length of stay, readmission rates, non-home discharge, home-time, higher social care requirements on discharge and amputation-free survival. Prognostic value will be compared by area under receiver operating characteristic curves. Continuous outcome variables will be analysed using Spearman's rank correlation coefficient. Interuser agreement will be compared by percentage agreement in Cohen's kappa coefficient.  ETHICS AND DISSEMINATION: The study is sponsored by National Health Service Greater Glasgow and Clyde (R&IUGN23CE014). London-Riverside REC (23/PR/0062) granted ethical approval. Results will be disseminated through publication in peer-reviewed vascular surgery and geriatric medicine themed journals and presentation at similar scientific conferences.

TRIALS REGISTRATION NUMBER

NCT06040658. Stage of study: pre-results.