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Kazemi F, Ahmed AK, Roy JM, Kuo CC, Jimenez AE, Rincon-Torroella J, Jackson C, Bettegowda C, Weingart J, Mukherjee D. Hospital frailty risk score predicts high-value care outcomes following brain metastasis resection. Clin Neurol Neurosurg 2024; 245:108497. [PMID: 39116796 DOI: 10.1016/j.clineuro.2024.108497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE Brain metastases (BM) are the most common adult intracranial tumors, representing a significant source of morbidity in patients with systemic malignancy. Frailty indices, including 11- and 5-factor modified frailty indices (mFI-11 and mFI-5), American Society of Anesthesiologists (ASA) physical status classification, and Charlson Comorbidity Index (CCI), have recently demonstrated an important role in predicting high-value care outcomes in neurosurgery. This study aims to investigate the efficacy of the newly developed Hospital Frailty Risk Score (HFRS) on postoperative outcomes in BM patients. METHODS Adult patients with BM treated surgically at a single institution were identified (2017-2019). HFRS was calculated using ICD-10 codes, and patients were subsequently separated into low (<5), intermediate (5-15), and high (>15) HFRS cohorts. Multivariate logistic regressions were utilized to identify associations between HFRS and complications, length of stay (LOS), hospital charges, and discharge disposition. Model discrimination was assessed using receiver operating characteristic (ROC) curves. RESULTS A total of 356 patients (mean age: 61.81±11.63 years; 50.6 % female) were included. The mean±SD for HFRS, mFI-11, mFI-5, ASA, and CCI were 6.46±5.73, 1.31±1.24, 0.95±0.86, 2.94±0.48, and 8.69±2.07, respectively. On multivariate analysis, higher HFRS was significantly associated with greater complication rate (OR=1.10, p<0.001), extended LOS (OR=1.13, p<0.001), high hospital charges (OR=1.14, p<0.001), and nonroutine discharge disposition (OR=1.12, p<0.001), and comparing the ROC curves of mFI-11, mFI-5, ASA,and CCI, the predictive accuracy of HFRS was the most superior for all four outcomes assessed. CONCLUSION The predictive ability of HFRS on BM resection outcomes may be superior than other frailty indices, offering a new avenue for routine preoperative frailty assessment and for managing postoperative expectations.
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Affiliation(s)
- Foad Kazemi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Joanna M Roy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cathleen C Kuo
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, United States
| | - Adrian E Jimenez
- Department of Neurosurgery, Columbia University Medical Center, New York City, NY, United States
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christopher Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Gupta K, Williams E, Warburton EA, Evans NR. Pre-Stroke Frailty and Outcomes following Percutaneous Endoscopic Gastrostomy Tube Insertion. Healthcare (Basel) 2024; 12:1557. [PMID: 39201117 PMCID: PMC11353361 DOI: 10.3390/healthcare12161557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/23/2024] [Accepted: 08/05/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND Frailty is common in stroke, where it exerts disease- and treatment-modifying effects. However, there has been little work evaluating how frailty influences outcomes after percutaneous endoscopic gastrostomy (PEG) tube insertion. This study investigates the relationship between pre-stroke frailty and one-year mortality following PEG insertion. METHODS A pre-stroke frailty index (FI) was calculated for individuals with post-stroke dysphagia who underwent PEG insertion between March 2019 and February 2021. Mortality was recorded at one year, as well as instances of post-PEG pneumonia and discharge destination. RESULTS Twenty-nine individuals underwent PEG insertion, eleven (37.9%) of whom died in the subsequent year. The mean (SD) FI for those who survived was 0.10 (0.09), compared to 0.27 (0.19) for those who died (p = 0.02). This remained significant after adjustment for age and sex, with each 0.1 increase in the FI independently associated with an increased odds of one-year mortality (aOR 1.39, 95% CI 1.17-1.67). There was no association between frailty and post-PEG pneumonia (0.12 (0.21) in those who aspirated versus 0.11 (0.18) in those who did not, p = 0.75). CONCLUSIONS Pre-stroke frailty is associated with increased one-year mortality after PEG, a finding that may help inform shared clinical decision-making in complex decisions regarding PEG feeding.
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Affiliation(s)
- Karan Gupta
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (K.G.); (E.A.W.)
| | - Eleanor Williams
- Department of Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK;
| | - Elizabeth A. Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (K.G.); (E.A.W.)
| | - Nicholas Richard Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (K.G.); (E.A.W.)
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Ali S, Kumar M, Khlidj Y, Hendricks E, Farooq F, Alruwaili W, Keisham B, Duhan S, Gonuguntla K, Sattar Y, Shaik A, Brar V, Asad ZUA, Sorajja D, Dominic P, Helmy T. Impact of frailty in hospitalized patients undergoing catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2024. [PMID: 39075813 DOI: 10.1111/jce.16383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/28/2024] [Accepted: 07/20/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Catheter Ablation (CA) is an effective treatment for atrial fibrillation (AF). However, frail elderly patients have been understudied due to their exclusion from landmark trials. OBJECTIVES Our study aims to evaluate outcomes in this population. METHODS The national readmission database (2016-2020) was queried, and frailty categories were defined based on hospital risk frailty scores ≦5 as low while >5 as intermediate/high frailty (IHF). We used multivariate regression and propensity-matched analysis to compare outcomes in patients undergoing CA for atrial fibrillation based on frailty index. RESULTS Among 55 936 CAs for AF, 33,248 patients had low frailty, while 22 688 had intermediate/high frailty (IHF). After propensity matching (N 12 448), IHF patients were found to have higher adverse events, including mortality (3% vs. 0.3%, p < .001), stroke (1.9% vs. 0.2%, p < .001), acute heart failure (53.8% vs. 42.2%, p < .001), AKI (42.5% vs. 6.8%, p < .001), pericardial complications (2.8 vs. 1.6%, p < .001), respiratory complications (27.8 vs. 7.2%, p < .001), major adverse cardiovascular events (21.2 vs. 9.4%, p < .001) and net adverse events (76.7 vs. 55%, p < .001). IHF patients had higher readmissions at 30 (15.5 vs. 12.6%, p < .001), 90 (31.9 vs. 25.1%, p < .001), and 180-day (41 vs. 34.7%, p < .001) intervals. A higher median length of stay (LOS) (7 vs. 3 days, p < .001) and cost ($44 287 vs. $27 517, p < .001) at index admission and subsequent readmissions were also observed (p < .001). CONCLUSION Intermediate/high frailty patients undergoing catheter ablation had worse clinical outcomes, higher healthcare burden, and readmission rates. LOS has decreased in both groups from 2016 to 2020; however, total cost has increased.
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Affiliation(s)
- Shafaqat Ali
- Department of Internal Medicine, Louisiana State University, Shreveport, Louisiana, USA
| | - Manoj Kumar
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Yehya Khlidj
- Department of Medicine, University of Algiers 1, Algiers, Algeria
| | - Emily Hendricks
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Faryal Farooq
- Department of Medicine, Allama Iqbal Medical College Lahore, Lahore, Pakistan
| | - Waleed Alruwaili
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Bijeta Keisham
- Department of Medicine, Weifang Medical University, Weifang, China
| | - Sanchit Duhan
- Department of Cardiology, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Karthik Gonuguntla
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Ayesha Shaik
- Department of Cardiology, Hartford Hospital/University of Connecticut, Hartford, Connecticut, USA
| | - Vijaywant Brar
- Department of Cardiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Zain Ul Abideen Asad
- Department of Cardiology, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - Dan Sorajja
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Paari Dominic
- Department of Cardiology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Tarek Helmy
- Department of Cardiology, Louisiana State University, Shreveport, Louisiana, USA
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Dabhi N, Kumar J, Kellogg RT, Park MS. Mechanical thrombectomy for treatment of acute ischemic stroke in frail patients: a systematic review of the literature. J Neurointerv Surg 2024; 16:788-793. [PMID: 37487691 DOI: 10.1136/jnis-2023-020476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND The overall safety and efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in frail patients is not well delineated. This systematic review aims to summarize and compare outcomes in frail and non-frail patients who underwent MT for AIS. METHODS A systematic review of the literature was performed using PubMed, Ovid Medline, and Web of Science to identify studies with outcomes-related data for frail patients with MT-treated AIS. The recanalization rate, procedural complications, and clinical outcome at 90-day follow-up were collected. RESULTS In the four included studies there were 642 frail patients and 499 non-frail patients. Frail patients had reduced rates of good functional outcomes (29% vs 42%; χ2=22, p<0.01) and increased 90-day mortality (51% vs 25%; χ2=38, p<0.01) compared with non-frail patients. CONCLUSION MT for treatment of AIS in frail patients may be associated with worse rates of morbidity and mortality along with reduced efficacy. Given that no studies to date directly compare conservative measures with endovascular management for AIS in frail patients, more studies are required to further evaluate and identify characteristics that may improve outcomes in these patients.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
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Li J, Wan J, Wang H. Role of frailty in predicting outcomes after stroke: a systematic review and meta-analysis. Front Psychiatry 2024; 15:1347476. [PMID: 39035605 PMCID: PMC11257970 DOI: 10.3389/fpsyt.2024.1347476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 06/03/2024] [Indexed: 07/23/2024] Open
Abstract
Background Stroke is considered the second most common cause of death and the third leading cause of disability worldwide. Frailty, characterized by increased vulnerability to stressors, is emerging as a key factor affecting outcomes in older adults and stroke patients. This study aimed to estimate the prevalence of frailty in acute stroke patients and assess its association with mortality and poor functional outcome. Methods Medline, Google Scholar, and Science Direct databases were systematically searched for English-language studies that included adult stroke patients (>16 years), have defined frailty, and reported mortality and functional outcomes. Meta-analysis was done using STATA 14.2, and the results were expressed as pooled odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic and the Chi-square test. Study quality was evaluated using the Newcastle Ottawa Scale (NOS). Results Twenty-five studies were included in the analysis. Frailty prevalence in stroke patients was 23% (95% CI 22% - 23%). Unadjusted analysis showed an OR of 2.66 (95% CI: 1.93 - 3.67) for mortality and 2.04 (95% CI: 1.49 - 2.80) for poor functional outcome. Adjusted estimates indicated an OR of 1.22 (95% CI: 1.1 - 1.35) for mortality and 1.21 (95% CI: 1.04 - 1.41) for poor functional outcome, with substantial heterogeneity for both adjusted and unadjusted analyses. No publication bias was detected for the prevalence of frailty. However, there was a publication bias for the association between frailty and mortality. Conclusions Frailty was significantly associated with increased mortality and poorer functional outcomes in stroke patients. Our study highlights the need to focus on frailty in stroke patients to improve outcomes and quality of life. Further research should aim to standardize assessment of frailty and reduce heterogeneity in study outcomes. Systematic review registration https://www.crd.york.ac.uk/prospero/#searchadvanced, CRD42023470325.
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Affiliation(s)
- Jing Li
- Department of Neurology, People’s Hospital of Anji, Anji County, Huzhou, Zhejiang, China
| | - Jinping Wan
- Department of Neurology, Guigang City People’s Hospital, Guigang, Guangxi, China
| | - Hua Wang
- Department of Neurology, People’s Hospital of Anji, Anji County, Huzhou, Zhejiang, China
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He H, Liu M, Li L, Zheng Y, Nie Y, Xiao LD, Li Y, Tang S. The impact of frailty on short-term prognosis in discharged adult stroke patients: A multicenter prospective cohort study. Int J Nurs Stud 2024; 154:104735. [PMID: 38521005 DOI: 10.1016/j.ijnurstu.2024.104735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/02/2024] [Accepted: 02/24/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Frailty is commonly observed in stroke patients and it is associated with adverse outcomes. However, there remains a gap in longitudinal studies investigating the causal relationship between baseline frailty and short-term prognosis in discharged adult stroke patients. OBJECTIVE To examine the causal impact of frailty on non-elective readmission and major adverse cardiac and cerebral events, and investigate its associations with cognitive impairment and post-stroke disability. DESIGN A multicenter prospective cohort study. SETTING Two tertiary hospitals in Central and Northwest China. PARTICIPANTS 667 adult stroke patients in stroke units were included from January 2022 to June 2022. METHODS Baseline frailty was assessed by the Frailty Scale. Custom-designed questions were utilized to assess non-elective readmission and major adverse cardiac and cerebral events as primary outcomes. Cognitive impairment, assessed using the Mini-Mental State Examination Scale (MMSE), and post-stroke disability, measured with the Modified Rankin Scale (mRS), were considered secondary outcomes at a 3-month follow-up. The impact of baseline frailty on non-elective readmission and major adverse cardiac and cerebral events was examined using bivariate and multiple Cox regression analyses. Furthermore, associations between baseline frailty and cognitive impairment, or post-stroke disability, were investigated through generalized linear models. RESULTS A total of 5 participants died, 12 had major adverse cardiac and cerebral events, and 57 had non-selective readmission among 667 adult stroke patients. Frailty was an independent risk factor for non-selective readmission (hazard ratio [HR]: 2.71, 95 % confidence interval [CI]: 1.59, 4.62) and major adverse cardiac and cerebral events (HR: 3.77, 95 % CI: 1.07, 13.22) for stroke patients. Baseline frailty was correlated with cognitive impairment (regression coefficient [β]: -2.68, 95 % CI: -3.78, -1.58) adjusting for socio-demographic and clinical factors and follow-up interval. However, the relationship between frailty and cognitive impairment did not reach statistical significance when further adjusting for baseline MMSE (β: -0.39, 95 % CI: -1.43, 0.64). Moreover, baseline frailty was associated with post-stroke disability (β: 0.36, 95 % CI: 0.08, 0.65) adjusting for socio-demographic and clinical variables, follow-up interval, and baseline mRS. CONCLUSIONS The finding highlights the importance of assessing baseline frailty in discharged adult stroke patients, as it is significantly associated with non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability at 3 months. These results highlight the crucial role of screening and evaluating frailty status in improving short-term prognosis for adult stroke patients. Interventions should be developed to address baseline frailty and mitigate the short-term prognosis of stroke. TWEETABLE ABSTRACT Baseline frailty predicts non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability in adult stroke patients. @haiyanhexyyy.
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Affiliation(s)
- Haiyan He
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China; International Medical Centre, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Minhui Liu
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China.
| | - Li Li
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yueping Zheng
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Centre for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuqin Nie
- Department of Nursing, the Second Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Lily Dongxia Xiao
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
| | - Yinglan Li
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya School of Nursing, Central South University, Changsha, Hunan, China.
| | - Siyuan Tang
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China.
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Dicpinigaitis AJ, Khamzina Y, Hall DE, Nassereldine H, Kennedy J, Seymour CW, Schmidt M, Reitz KM, Bowers CA. Adaptation of the Risk Analysis Index for Frailty Assessment Using Diagnostic Codes. JAMA Netw Open 2024; 7:e2413166. [PMID: 38787554 PMCID: PMC11127118 DOI: 10.1001/jamanetworkopen.2024.13166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/23/2024] [Indexed: 05/25/2024] Open
Abstract
Importance Frailty is associated with adverse outcomes after even minor physiologic stressors. The validated Risk Analysis Index (RAI) quantifies frailty; however, existing methods limit application to in-person interview (clinical RAI) and quality improvement datasets (administrative RAI). Objective To expand the utility of the RAI utility to available International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) administrative data, using the National Inpatient Sample (NIS). Design, Setting, and Participants RAI parameters were systematically adapted to ICD-10-CM codes (RAI-ICD) and were derived (NIS 2019) and validated (NIS 2020). The primary analysis included survey-weighed discharge data among adults undergoing major surgical procedures. Additional external validation occurred by including all operative and nonoperative hospitalizations in the NIS (2020) and in a multihospital health care system (UPMC, 2021-2022). Data analysis was conducted from January to May 2023. Exposures RAI parameters and in-hospital mortality. Main Outcomes and Measures The association of RAI parameters with in-hospital mortality was calculated and weighted using logistic regression, generating an integerized RAI-ICD score. After initial validation, thresholds defining categories of frailty were selected by a full complement of test statistics. Rates of elective admission, length of stay, hospital charges, and in-hospital mortality were compared across frailty categories. C statistics estimated model discrimination. Results RAI-ICD parameters were weighted in the 9 548 206 patients who were hospitalized (mean [SE] age, 55.4 (0.1) years; 3 742 330 male [weighted percentage, 39.2%] and 5 804 431 female [weighted percentage, 60.8%]), modeling in-hospital mortality (2.1%; 95% CI, 2.1%-2.2%) with excellent derivation discrimination (C statistic, 0.810; 95% CI, 0.808-0.813). The 11 RAI-ICD parameters were adapted to 323 ICD-10-CM codes. The operative validation population of 8 113 950 patients (mean [SE] age, 54.4 (0.1) years; 3 148 273 male [weighted percentage, 38.8%] and 4 965 737 female [weighted percentage, 61.2%]; in-hospital mortality, 2.5% [95% CI, 2.4%-2.5%]) mirrored the derivation population. In validation, the weighted and integerized RAI-ICD yielded good to excellent discrimination in the NIS operative sample (C statistic, 0.784; 95% CI, 0.782-0.786), NIS operative and nonoperative sample (C statistic, 0.778; 95% CI, 0.777-0.779), and the UPMC operative and nonoperative sample (C statistic, 0.860; 95% CI, 0.857-0.862). Thresholds defining robust (RAI-ICD <27), normal (RAI-ICD, 27-35), frail (RAI-ICD, 36-45), and very frail (RAI-ICD >45) strata of frailty maximized precision (F1 = 0.33) and sensitivity and specificity (Matthews correlation coefficient = 0.26). Adverse outcomes increased with increasing frailty. Conclusion and Relevance In this cohort study of hospitalized adults, the RAI-ICD was rigorously adapted, derived, and validated. These findings suggest that the RAI-ICD can extend the quantification of frailty to inpatient adult ICD-10-CM-coded patient care datasets.
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Affiliation(s)
- Alis J. Dicpinigaitis
- Department of Neurology, New York Presbyterian–Weill Cornell Medical Center, New York, New York
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | | | - Daniel E. Hall
- Department of Neurology, New York Presbyterian–Weill Cornell Medical Center, New York, New York
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Hasan Nassereldine
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Meic Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | - Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
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Joundi RA, King JA, Stang J, Nicol D, Hill MD, Yu AYX, Kapral MK, Smith EE. Age-Specific Association of Co-Morbidity With Home-Time After Acute Stroke. Can J Neurol Sci 2024:1-9. [PMID: 38532570 DOI: 10.1017/cjn.2024.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To examine the association of co-morbidity with home-time after acute stroke and whether the association is influenced by age. METHODS We conducted a province-wide study using linked administrative databases to identify all admissions for first acute ischemic stroke or intracerebral hemorrhage between 2007 and 2018 in Alberta, Canada. We used ischemic stroke-weighted Charlson Co-morbidity Index of 3 or more to identify those with severe co-morbidity. We used zero-inflated negative binomial models to determine the association of severe co-morbidity with 90-day and 1-year home-time, and logistic models for achieving ≥ 80 out of 90 days of home-time, assessing for effect modification by age and adjusting for sex, stroke type, comprehensive stroke center care, hypertension, atrial fibrillation, year of study, and separately adjusting for estimated stroke severity. We also evaluated individual co-morbidities. RESULTS Among 28,672 patients in our final cohort, severe co-morbidity was present in 27.7% and was associated with lower home-time, with a greater number of days lost at younger age (-13 days at age < 60 compared to -7 days at age 80+ years for 90-day home-time; -69 days at age < 60 compared to -51 days at age 80+ years for 1-year home-time). The reduction in probability of achieving ≥ 80 days of home-time was also greater at younger age (-22.7% at age < 60 years compared to -9.0% at age 80+ years). Results were attenuated but remained significant after adjusting for estimated stroke severity and excluding those who died. Myocardial infarction, diabetes, and cancer/metastases had a greater association with lower home-time at younger age, and those with dementia had the greatest reduction in home time. CONCLUSION Severe co-morbidity in acute stroke is associated with lower home-time, more strongly at younger age.
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Affiliation(s)
- Raed A Joundi
- Division of Neurology, Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - James A King
- Provincial Research Data Services, Alberta Health Services, Alberta Strategy for Patient Oriented Research Support Unit Data Platform, Calgary, AB, Canada
| | - Jillian Stang
- Data and Analytics (DnA), Alberta Health Services, Edmonton, AB, Canada
| | - Dana Nicol
- Data and Analytics (DnA), Alberta Health Services, Edmonton, AB, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Amy Y X Yu
- ICES, Toronto, ON, Canada
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Moira K Kapral
- ICES, Toronto, ON, Canada
- Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric E Smith
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Covell MM, Roy JM, Rumalla K, Dicpinigaitis AJ, Kazim SF, Hall DE, Schmidt MH, Bowers CA. The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review. Neurosurgery 2024; 94:251-262. [PMID: 37695046 DOI: 10.1227/neu.0000000000002668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Hospital Frailty Risk Score (HFRS) is an International Classification of Disease 10th Revision-based scale that was originally designed for, and validated in, the assessment of patients 75 years or older presenting in an acute care setting. This study highlights central tenets inherent to the concept of frailty; questions the logic behind, and utility of, HFRS' recent implementation in the neurosurgical literature; and discusses why there is no useful role for HFRS as a frailty-based neurosurgical risk assessment (FBNRA) tool. METHODS The authors performed a systematic review of the literature per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all cranial and spinal studies that used HFRS as their primary frailty tool. Seventeen (N = 17) studies used HFRS to assess frailty's impact on neurosurgical outcomes. Thirteen total journals, 10 of which were neurosurgical journals, including the highest impact factor journals, published the 17 papers. RESULTS Increasing HFRS score was associated with adverse outcomes, including prolonged length of stay (11 of 17 studies), nonroutine discharge (10 of 17 studies), and increased hospital costs (9 of 17 studies). Four different HFRS studies, of the 17, predicted one of the following 4 adverse outcomes: worse quality of life, worse functional outcomes, reoperation, or in-hospital mortality. CONCLUSION Despite its rapid acceptance and widespread proliferation through the leading neurosurgical journals, HFRS lacks any conceptual relationship to the frailty syndrome or FBNRA for individual patients. HFRS measures acute conditions using International Classification of Disease 10th Revision codes and awards "frailty" points for symptoms and examination findings unrelated to the impaired baseline physiological reserve inherent to the very definition of frailty. HFRS lacks clinical utility as it cannot be deployed point-of-care at the bedside to risk stratify patients. HFRS has never been validated in any patient population younger than 75 years or in any nonacute care setting. We recommend HFRS be discontinued as an individual FBNRA tool.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington , District of Columbia , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Joanna Mary Roy
- Topiwala National Medical College, Mumbai , India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla , New York , USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
- Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh , Pennsylvania , USA
- Wolff Center at UPMC, Pittsburgh , Pennsylvania , USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
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10
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Dagra A, Rezk R, Lucke-Wold B. Commentary: The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review. Neurosurgery 2024; 94:e18-e19. [PMID: 37930134 DOI: 10.1227/neu.0000000000002751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Affiliation(s)
- Abeer Dagra
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
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11
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Xu L, Shao Z, Huang H, Li D, Wang T, Atyah M, Zhou W, Yang Z. Impact of Frailty on Short-Term Outcomes of Hepatic Lobectomy in Patients with Intrahepatic Cholangiocarcinoma: Evidence from the US Nationwide Inpatient Sample 2005-2018. Dig Surg 2024; 41:42-52. [PMID: 38295782 DOI: 10.1159/000536401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 01/17/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION This study aimed to evaluate associations between frailty and outcomes in patients with intrahepatic cholangiocarcinoma (ICC) undergoing hepatic lobectomy using a large, nationally representative sample. METHODS This population-based, retrospective observational study extracted the data of adults ≥20 years old with ICC undergoing hepatic lobectomy from the US Nationwide Inpatient Sample database between 2005 and 2018. Frailty was assessed by the validated Hospital Frailty Risk Score (HFRS). Associations between frailty and surgical outcomes were analyzed using logistic regression analyses. RESULTS After exclusions, 777 patients were enrolled, including 427 frail and 350 non-frail. Patients' mean age was 64.5 (±0.4) years and the majority were males (51.1%) and whites (76.5%). Frailty was significantly associated with increased odds of in-hospital mortality (aOR: 18.51, 95% CI: 6.70, 51.18), non-home discharge (aOR: 3.58, 95% CI: 2.26, 5.66), prolonged LOS (aOR: 5.56, 95% CI: 3.87, 7.99), perioperative cardiac arrest/stroke (aOR: 5.44, 95% CI: 1.62, 18.24), acute respiratory distress syndrome (ARDS)/respiratory failure (aOR: 3.88, 95% CI: 2.40, 6.28), tracheostomy/ventilation (aOR: 3.83, 95% CI: 2.23, 6.58), bleeding/transfusion (aOR: 1.67, 95% CI: 1.24, 2.26), acute kidney injury (AKI) (aOR: 14.37, 95% CI: 7.13, 28.99), postoperative shock (aOR: 4.44, 95% CI: 2.54, 7.74), and sepsis (aOR: 11.94, 95% CI: 6.90, 20.67). DISCUSSION/CONCLUSION Among patients with ICC undergoing hepatic lobectomy, HFRS-defined frailty is a strong predictor of worse in-patient outcomes, including in-hospital death, prolonged LOS, unfavorable discharge, and complications (perioperative cardiac arrest/stroke, ARDS/respiratory failure, tracheostomy/ventilation, bleeding/transfusion, AKI, postoperative shock, and sepsis). Study results may help stratify risk in frail patients undergoing hepatic resection for ICC.
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Affiliation(s)
- Li Xu
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhuo Shao
- Department of Clinical Laboratory, China-Japan Friendship Hospital, Beijing, China
| | - Hanchun Huang
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Friendship Hospital, Beijing, China
- Graduate School, Peking Union Medical College, Beijing, China
| | | | - Tianxiao Wang
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Friendship Hospital, Beijing, China
- Graduate School, Peking University Health Science Center, Beijing, China
| | - Manar Atyah
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Wenying Zhou
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhiying Yang
- Department of Hepatobiliary and Pancreatic Surgery, China-Japan Friendship Hospital, Beijing, China
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12
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Takahashi PY, Thorsteinsdottir B, McCoy RG, Ramar P, Canning RE, Hanson GJ, Baumbach LJ, Chandra A, Philpot LM. Impact of Program Changes Including Telemedicine and Telephonic Care During the COVID-19 Pandemic in Preventing 30-Day Hospital Readmission for Patients in a Care Transitions Program. J Prim Care Community Health 2024; 15:21501319241226547. [PMID: 38270059 PMCID: PMC10812102 DOI: 10.1177/21501319241226547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION/OBJECTIVES To describe health outcomes of older adults enrolled in the Mayo Clinic Care Transitions (MCCT) program before and during the COVID-19 pandemic compared to unenrolled patients. METHODS We conducted a retrospective cohort study of adults (age >60 years) in the MCCT program compared to a usual care control group from January 1, 2019, to September 20, 2022. The MCCT program involved a home, telephonic, or telemedicine visit by an advanced care provider. Outcomes were 30- and 180-day hospital readmissions, emergency department (ED) visit, and mortality. We performed a subgroup analysis after March 1, 2020 (during the pandemic). We analyzed data with Cox proportional hazards regression models and hazard ratios (HRs) with 95% CIs. RESULTS Of the 1,012 patients total, 354 were in the MCCT program and 658 were in the usual care group with a mean (SD) age of 81.1 (9.1) years overall. Thirty-day readmission was 16.9% (60 of 354) for MCCT patients and 14.7% (97 of 658) for usual care patients (HR, 1.24; 95% CI, 0.88-1.75). During the pandemic, the 30-day readmission rate was 15.1% (28 of 186) for MCCT patients and 14.9% (68 of 455) for usual care patients (HR, 1.20; 95% CI, 0.75-1.91). There was no difference between groups for 180-day hospitalization, 30- or 180-day ED visit, and 30- or 180-day mortality. CONCLUSIONS Numerous factors involving patients, providers, and health care delivery systems during the pandemic most likely contributed to these findings.
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Affiliation(s)
| | | | - Rozalina G. McCoy
- Mayo Clinic, Rochester, MN, USA
- University of Maryland School of Medicine, Baltimore, MD
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
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13
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Sokhal BS, Menon SPK, Willes C, Corp N, Matetić A, Mallen C, Mamas M. Systematic Review of the Association of the Hospital Frailty Risk Score with Mortality in Patients with Cerebrovascular and Cardiovascular Disease. Curr Cardiol Rev 2024; 20:45-62. [PMID: 38425103 DOI: 10.2174/011573403x276647240217112151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/26/2023] [Accepted: 12/14/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND There is limited systematic data on the association between the Hospital Frailty Risk Score (HFRS) and characteristics and mortality in patients with cerebrovascular and cardiovascular disease (CVD). This systematic review aimed to summarise the use of the HFRS in describing the prevalence of frailty in patients with CVD, the clinical characteristics of patients with CVD, and the association between frailty on the likelihood of mortality in patients with CVD. METHODS A systematic literature search for observational studies using terms related to CVD, cerebrovascular disease, and the HFRS was conducted using 6 databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were appraised using the Newcastle-Ottawa Scale (NOS). RESULTS Seventeen observational studies were included, all rated 'good' quality according to the NOS. One study investigated 5 different CVD cohorts (atrial fibrillation (AF), heart failure (HF), hypotension, hypertension, and chronic ischemic heart disease), 1 study investigated 2 different CVD cohorts (AF and acute myocardial infarction (AMI)), 6 studies investigated HF, 3 studies investigated AMI, 4 studies investigated stroke, 1 study investigated AF, and 1 study investigated cardiac arrest. Increasing frailty risk category was associated with increased age, female sex, and non-white racial group across all CVD. Increasing frailty risk category is also associated with increased length of hospital stay, total costs, and increased odds of 30-day all-cause mortality across all CVD. CONCLUSIONS The HFRS is an efficient and effective tool for stratifying frailty in patients with CVD and predicting adverse health outcomes.
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Affiliation(s)
- Balamrit Singh Sokhal
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
| | | | - Charles Willes
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
| | - Nadia Corp
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
| | - Andrija Matetić
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
- Department of Cardiology, University Hospital of Split, Split 21000, Croatia
| | - Christian Mallen
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom
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14
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Dengler J, Gheewala H, Kraft CN, Hegewald AA, Dörre R, Heese O, Gerlach R, Rosahl S, Maier B, Burger R, Wutzler S, Carl B, Ryang YM, Hau KT, Stein G, Gulow J, Allam A, Abduljawwad N, Rico Gonzalez G, Kuhlen R, Hohenstein S, Bollmann A, Stoffel M. Changes in frailty among patients hospitalized for spine pathologies during the COVID-19 pandemic in Germany-a nationwide observational study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:19-30. [PMID: 37971536 DOI: 10.1007/s00586-023-08014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE In spine care, frailty is associated with poor outcomes. The aim of this study was to describe changes in frailty in spine care during the coronavirus disease 2019 (COVID-19) pandemic and their relation to surgical management and outcomes. METHODS Patients hospitalized for spine pathologies between January 1, 2019, and May 17, 2022, within a nationwide network of 76 hospitals in Germany were retrospectively included. Patient frailty, types of surgery, and in-hospital mortality rates were compared between pandemic and pre-pandemic periods. RESULTS Of the 223,418 included patients with spine pathologies, 151,766 were admitted during the pandemic and 71,652 during corresponding pre-pandemic periods in 2019. During the pandemic, the proportion of high-frailty patients increased from a range of 5.1-6.1% to 6.5-8.8% (p < 0.01), while the proportion of low frailty patients decreased from a range of 70.5-71.4% to 65.5-70.1% (p < 0.01). In most phases of the pandemic, the Elixhauser comorbidity index (ECI) showed larger increases among high compared to low frailty patients (by 0.2-1.8 vs. 0.2-0.8 [p < 0.01]). Changes in rates of spine surgery were associated with frailty, most clearly in rates of spine fusion, showing consistent increases among low frailty patients (by 2.2-2.5%) versus decreases (by 0.3-0.8%) among high-frailty patients (p < 0.02). Changes in rates of in-hospital mortality were not associated with frailty. CONCLUSIONS During the COVID-19 pandemic, the proportion of high-frailty patients increased among those hospitalized for spine pathologies in Germany. Low frailty was associated with a rise in rates of spine surgery and high frailty with comparably larger increases in rates of comorbidities.
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Affiliation(s)
- Julius Dengler
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany.
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany.
| | - Hussain Gheewala
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Clayton N Kraft
- Department of Orthopedics, Trauma Surgery and Hand Unit, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Aldemar A Hegewald
- Department of Neurosurgery, VAMED Ostsee Hospital Damp, Ostseebad Damp, Germany
| | - Ralf Dörre
- Department of Neurosurgery, HELIOS Hospital St. Marienberg, Helmstedt, Germany
| | - Oliver Heese
- Department of Neurosurgery and Spinal Surgery, HELIOS Hospital Schwerin - University Campus of MSH Medical School Hamburg, Schwerin, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Steffen Rosahl
- Department of Neurosurgery, HELIOS Hospital Erfurt, Erfurt, Germany
| | - Bernd Maier
- Department of Trauma and Orthopedic Surgery, HELIOS Hospital Pforzheim, Pforzheim, Germany
| | - Ralf Burger
- Department of Neurosurgery, HELIOS Hospital Uelzen, Uelzen, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand and Orthopedic Surgery, HELIOS Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
- Department of Neurosurgery, HELIOS Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery and Spine Center, HELIOS Hospital Berlin Buch, Berlin, Germany
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Khanh Toan Hau
- Department of Spine Surgery, HELIOS Hospital Duisburg, Duisburg, Germany
| | - Gregor Stein
- Department of Orthopaedic, Trauma and Spine Surgery, HELIOS Hospital Siegburg, Siegburg, Germany
| | - Jens Gulow
- Department of Spine Surgery, HELIOS Park-Klinikum Leipzig, Leipzig, Germany
| | - Ali Allam
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Nehad Abduljawwad
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | - Gerardo Rico Gonzalez
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Bad Saarow, Germany
- Department of Neurosurgery, HELIOS Hospital Bad Saarow, Bad Saarow, Germany
| | | | - Sven Hohenstein
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Andreas Bollmann
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
- Department of Electrophysiology, Heart Center Leipzig at Leipzig University, Leipzig, Germany
| | - Michael Stoffel
- Department of Neurosurgery, HELIOS Hospital Krefeld, Krefeld, Germany
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15
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Cai H, Zhang H, Liang J, Liu Z, Huang G. Genetic liability to frailty in relation to functional outcome after ischemic stroke. Int J Stroke 2024; 19:50-57. [PMID: 37542426 DOI: 10.1177/17474930231194676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
BACKGROUND Frailty appears to be associated with unfavorable prognosis after stroke in observational studies, but the causality remains largely unknown. AIMS The aim of this study is to investigate the potential causal effect of frailty on functional outcome at 3 months after ischemic stroke using the Mendelian randomization (MR) framework. METHODS Genetic instruments for frailty index were identified in a genome-wide association study meta-analysis including 175,226 individuals of European descent. Corresponding genetic association estimates for functional outcome after ischemic stroke at 90 days were taken from the Genetic of Ischemic Stroke Functional Outcome (GISCOME) network of 6021 patients. We performed inverse-variance weighted MR as the main analyses, followed by several alternate methods and sensitivity analyses. RESULTS In univariable MR, we found evidence that genetically predicted higher frailty index (odds ratio (OR) = 5.12; 95% confidence interval (CI) = 1.31-20.09; p = 0.019) was associated with worse functional outcome (modified Rankin Scale score ⩾3) after ischemic stroke. In further multivariable MR adjusting for potential confounding traits including body mass index, C-reactive protein, inflammatory bowel disease, and smoking initiation, the overall patterns between genetic liability to frailty and poor functional outcome status remained. Sensitivity analyses with complementary methods and with model unadjusted for baseline stroke severity (OR = 4.19; 95% CI = 1.26-13.90; p = 0.019) yielded broadly concordant results. CONCLUSIONS The present MR study suggested a possible causal effect of frailty on poor functional outcome after ischemic stroke. Frailty might represent a potential target for intervention to improve recovery after ischemic stroke.
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Affiliation(s)
- Huan Cai
- Department of Rehabilitation Medicine, Zhongshan City People's Hospital, Zhongshan, China
| | - Hao Zhang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jialin Liang
- Department of Endocrinology and Metabolism, Zhongshan City People's Hospital, Zhongshan, China
| | - Zhonghua Liu
- Department of Rehabilitation Medicine, Zhongshan City People's Hospital, Zhongshan, China
| | - Guozhi Huang
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- School of Rehabilitation Medicine, Southern Medical University, Guangzhou, China
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16
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Shah S, Spirollari E, Ng C, Cordeiro K, Clare K, Nolan B, Naftchi AF, Carpenter AB, Dominguez JF, Kaplan I, Bass B, Harper E, Rosenberg J, Chandy D, Mayer SA, Prabhakaran K, Wang A, Gandhi CD, Al-Mufti F. Early tracheostomy in patients undergoing mechanical thrombectomy for acute ischemic stroke. J Crit Care 2023; 78:154357. [PMID: 37336143 DOI: 10.1016/j.jcrc.2023.154357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/21/2023] [Accepted: 06/05/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Respiratory failure following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a known complication, and requirement of tracheostomy is associated with worse outcomes. Our objective is to evaluate characteristics associated with tracheostomy timing in AIS patients treated with MT. METHODS The National Inpatient Sample was queried for adult patients treated with MT for AIS from 2016 to 2019. Baseline demographic characteristics, comorbidities, and inpatient outcomes were analyzed for associations in patients who received tracheostomy. Timing of early tracheostomy (ETR) was defined as placement before day 8 of hospital stay. RESULTS Of 3505 AIS-MT patients who received tracheostomy, 915 (26.1%) underwent ETR. Patients who underwent ETR had shorter length of stay (LOS) (25.39 days vs 32.43 days, p < 0.001) and lower total hospital charges ($483,472.07 vs $612,362.86, p < 0.001). ETR did not confer a mortality benefit but was associated with less acute kidney injury (OR, 0.697; p = 0.013), pneumonia (OR, 0.449; p < 0.001), and sepsis (OR, 0.536; p = 0.002). CONCLUSION An expected increase in complications and healthcare resource utilization is seen in AIS-MT patients receiving tracheostomy, likely reflecting the severity of patients' post-stroke neurologic injury. Among these high-risk patients, ETR was predictive of shorter LOS and fewer complications.
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Affiliation(s)
- Smit Shah
- Department of Neurology, University of South Carolina/PRISMA Health Richland, Columbia, SC, United States of America
| | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, NY, United States of America
| | - Christina Ng
- School of Medicine, New York Medical College, Valhalla, NY, United States of America
| | - Kevin Cordeiro
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Kevin Clare
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Alexandria F Naftchi
- School of Medicine, New York Medical College, Valhalla, NY, United States of America
| | - Austin B Carpenter
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America.
| | - Ian Kaplan
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Brittany Bass
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Emily Harper
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Jon Rosenberg
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Dipak Chandy
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Kartik Prabhakaran
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Arthur Wang
- Department of Neurosurgery, Tulane University Medical Center, New Orleans, LA, United States of America
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America.
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17
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Westworth SE, Ung D, Dalli LL, Barnden R, Kilkenny MF, Srikanth V, Lannin NA, Lodge ME, Cadilhac DA, Olaiya MT, Andrew NE. Factors Associated With Transition From Community to Permanent Residential Aged Care Following Stroke: A Linked Registry Data Study. Stroke 2023; 54:3117-3127. [PMID: 37955141 DOI: 10.1161/strokeaha.123.043972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Understanding factors that influence the transition to permanent residential aged care following a stroke or transient ischemic attack may inform strategies to support people to live at home longer. We aimed to identify the demographic, clinical, and system factors that may influence the transition from living in the community to permanent residential care in the 6 to 18 months following stroke/transient ischemic attack. METHODS Linked data cohort analysis of adults from Queensland and Victoria aged ≥65 years and registered in the Australian Stroke Clinical Registry (2012-2016) with a clinical diagnosis of stroke/transient ischemic attack and living in the community in the first 6 months post-hospital discharge. Participant data were linked with primary care, pharmaceutical, aged care, death, and hospital data. Multivariable survival analysis was performed to determine demographic, clinical, and system factors associated with the transition to permanent residential care in the 6 to 18 months following stroke, with death modeled as a competing risk. RESULTS Of 11 176 included registrants (median age, 77.2 years; 44% female), 520 (5%) transitioned to permanent residential care between 6 and 18 months. Factors most associated with transition included the history of urinary tract infections (subhazard ratio [SHR], 1.41 [95% CI, 1.16-1.71]), dementia (SHR, 1.66 [95% CI, 1.14-2.42]), increasing age (65-74 versus 85+ years; SHR, 1.75 [95% CI, 1.31-2.34]), living in regional Australia (SHR, 31 [95% CI, 1.08-1.60]), and aged care service approvals: respite (SHR, 4.54 [95% CI, 3.51-5.85]) and high-level home support (SHR, 1.80 [95% CI, 1.30-2.48]). Protective factors included being dispensed antihypertensive medications (SHR, 0.68 [95% CI, 0.53-0.87]), seeing a cardiologist (SHR, 0.72 [95% CI, 0.57-0.91]) following stroke, and less severe stroke (SHR, 0.71 [95% CI, 0.58-0.88]). CONCLUSIONS Our findings provide an improved understanding of factors that influence the transition from community to permanent residential care following stroke and can inform future strategies designed to delay this transition.
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Affiliation(s)
- Sarah E Westworth
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia (S.E.W., D.U., R.B., V.S., M.E.L.)
| | - David Ung
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia (S.E.W., D.U., R.B., V.S., M.E.L.)
- National Centre for Healthy Ageing, Peninsula Health and Monash University, Frankston, Victoria, Australia (D.U., R.B., V.S., M.E.L., N.E.A.)
| | - Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (L.L.D., M.F.K., D.A.C., M.T.O.)
| | - Rebecca Barnden
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia (S.E.W., D.U., R.B., V.S., M.E.L.)
- National Centre for Healthy Ageing, Peninsula Health and Monash University, Frankston, Victoria, Australia (D.U., R.B., V.S., M.E.L., N.E.A.)
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (L.L.D., M.F.K., D.A.C., M.T.O.)
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia (M.F.K., D.A.C.)
| | - Velandai Srikanth
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia (S.E.W., D.U., R.B., V.S., M.E.L.)
- National Centre for Healthy Ageing, Peninsula Health and Monash University, Frankston, Victoria, Australia (D.U., R.B., V.S., M.E.L., N.E.A.)
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia (N.A.L.)
- Alfred Health, Melbourne, Victoria, Australia (N.A.L., M.E.L.)
| | - Margot E Lodge
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia (S.E.W., D.U., R.B., V.S., M.E.L.)
- National Centre for Healthy Ageing, Peninsula Health and Monash University, Frankston, Victoria, Australia (D.U., R.B., V.S., M.E.L., N.E.A.)
- Alfred Health, Melbourne, Victoria, Australia (N.A.L., M.E.L.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (L.L.D., M.F.K., D.A.C., M.T.O.)
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia (M.F.K., D.A.C.)
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (L.L.D., M.F.K., D.A.C., M.T.O.)
| | - Nadine E Andrew
- National Centre for Healthy Ageing, Peninsula Health and Monash University, Frankston, Victoria, Australia (D.U., R.B., V.S., M.E.L., N.E.A.)
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Sokhal BS, Matetić A, Abhishek A, Banerjee A, Partington R, Roddy E, Rashid M, Mallen CD, Mamas MA. Impact of Frailty on Emergency Department Encounters for Cardiovascular Disease: A Retrospective Cohort Study. Am J Cardiol 2023; 206:210-218. [PMID: 37708753 DOI: 10.1016/j.amjcard.2023.08.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023]
Abstract
Data are limited on whether the causes of emergency department (ED) encounters for cardiovascular diseases (CVDs) and associated clinical outcomes vary by frailty status. Using the United States Nationwide ED Sample, selected CVD encounters (acute myocardial infarction [AMI], ischemic stroke, atrial fibrillation [AF], heart failure [HF], pulmonary embolism, cardiac arrest, and hemorrhagic stroke) were stratified by hospital frailty risk score (HFRS). Logistic regression was used to determine the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of ED mortality among the different frailty groups. A total of 8,577,028 selected CVD ED encounters were included. A total of 5,120,843 (59.7%) had a low HFRS (<5), 3,041,699 (35.5%) had an intermediate HFRS (5 to 15), and 414,485 (4.8%) had a high HFRS (>15). Ischemic stroke was the most common reason for the encounter in the high HFRS group (66.9%), followed by hemorrhagic stroke (11.7%) and AMI (7.2%). For the low HFRS group, AF was the most common reason for the encounter (30.2%), followed by AMI (23.6%) and HF (16.8%). Compared with the low-risk group, high-risk patients had a decreased ED mortality and an increased overall mortality across most CVD encounters (p <0.001). The strongest association with overall mortality was observed among patients with a high HFRS admitted for AF (aOR 27.14, 95% CI 25.03 to 29.43) and HF (aOR 13.71, 95% CI 12.95 to 14.51) compared with their low-risk counterparts. In conclusion, patients presenting to the ED with acute CVD have a significant frailty burden, with different patterns of CVD according to frailty status. Frailty is associated with an increased all-cause mortality in patients for most CVD encounters.
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Affiliation(s)
- Balamrit Singh Sokhal
- School of Medicine; Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom
| | - Andrija Matetić
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom; Department of Cardiology, University Hospital of Split, Split, Croatia
| | - Abhishek Abhishek
- Academic Rheumatology, University of Nottingham, Nottingham, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | | | - Edward Roddy
- School of Medicine; Haywood Academic Rheumatology Centre, Midland Partnership Foundation Trust, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom
| | | | - Mamas Andreas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom.
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19
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Dalli LL, Borschmann K, Cooke S, Kilkenny MF, Andrew NE, Scott D, Ebeling PR, Lannin NA, Grimley R, Sundararajan V, Katzenellenbogen JM, Cadilhac DA. Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life. Stroke 2023; 54:2593-2601. [PMID: 37581266 DOI: 10.1161/strokeaha.123.043094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA. METHODS Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture. RESULTS Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%-80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05-1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21-1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77-3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10-1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49-0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort. CONCLUSIONS Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.
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Affiliation(s)
- Lachlan L Dalli
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.F.K., D.S., P.R.E., R.G., D.A.C.)
| | - Karen Borschmann
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia (K.B., M.F.K., D.A.C.)
- Allied Health Department, St Vincent's Hospital, Melbourne, VIC, Australia (K.B.)
| | - Shae Cooke
- Eastern Health, Box Hill, VIC, Australia (S.C.)
| | - Monique F Kilkenny
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.F.K., D.S., P.R.E., R.G., D.A.C.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia (K.B., M.F.K., D.A.C.)
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia (N.E.A.)
- National Centre for Healthy Ageing, Frankston, VIC, Australia (N.E.A.)
| | - David Scott
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.F.K., D.S., P.R.E., R.G., D.A.C.)
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia (D.S.)
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.F.K., D.S., P.R.E., R.G., D.A.C.)
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia (N.A.L.)
- Alfred Health, Melbourne, VIC, Australia (N.A.L.)
| | - Rohan Grimley
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.F.K., D.S., P.R.E., R.G., D.A.C.)
- Sunshine Coast Clinical School, School of Medicine, Griffith University, Birtinya, QLD, Australia (R.G.)
| | - Vijaya Sundararajan
- Department of Medicine, St Vincent's Hospital, Melbourne Medical School, University of Melbourne, VIC, Australia (V.S.)
| | - Judith M Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Perth, Australia (J.M.K.)
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.F.K., D.S., P.R.E., R.G., D.A.C.)
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia (K.B., M.F.K., D.A.C.)
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20
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Lakra A, Tram MK, Bernasek TL, Lyons ST, O'Connor CM. Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty. J Arthroplasty 2023; 38:S182-S186.e2. [PMID: 36858131 DOI: 10.1016/j.arth.2023.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA. METHODS Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests. RESULTS Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01). CONCLUSIONS Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA. TYPE OF STUDY Level III retrospective cohort study.
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Affiliation(s)
- Akshay Lakra
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York
| | - Michael K Tram
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York
| | - Thomas L Bernasek
- Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Steven T Lyons
- Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Casey M O'Connor
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York; Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
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21
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Renedo D, Acosta JN, Koo AB, Rivier C, Sujijantarat N, de Havenon A, Sharma R, Gill TM, Sheth KN, Falcone GJ, Matouk CC. Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses. Stroke 2023; 54:1538-1547. [PMID: 37216451 PMCID: PMC10212531 DOI: 10.1161/strokeaha.122.041891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/14/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists. DESIGN Observational study using data from All of Us research program and Mendelian Randomization analyses. METHODS Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk. RESULTS Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5-6.8]; P<0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3-15.7]; P<0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2-58.6]; P<0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately (P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15-1.84]; P=0.002). CONCLUSIONS Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.
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Affiliation(s)
- Daniela Renedo
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Julián N. Acosta
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Andrew B. Koo
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Cyprien Rivier
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Thomas M. Gill
- Department of Internal Medicine, Division of Geriatric Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Guido J. Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Charles C. Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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22
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Zhang Q, Gao X, Huang J, Xie Q, Zhang Y. Association of pre-stroke frailty and health-related factors with post-stroke functional independence among community-dwelling Chinese older adults. J Stroke Cerebrovasc Dis 2023; 32:107130. [PMID: 37058872 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023] Open
Abstract
OBJECTIVES Frailty is associated with a range of poor post-stroke outcomes. There is still a lack of comprehensive understanding of the temporal relationship between pre-stroke frailty status and other related factors with functional recovery after stroke. This study aims to evaluate pre-stroke frailty status and health-related factors associated with functional independence among community-dwelling Chinese older adults. MATERIALS AND METHODS The dataset based on the China Health and Retirement Longitudinal Study (CHARLS) conducted in 28 provinces across China was used. The pre-stroke frailty status was assessed using the Physical Frailty Phenotype (PFP) scale with the 2015 wave data. The PFP scale consisted of five criteria with a total score of 5, and categorized into non-frail (0 point), prefrail (1 and 2 points), and frail (3 or more points). Covariates included demographic factors (age, sex, marital status, residence, and education level) and health-related variables (comorbidities, self-reported health status and cognition). Activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed as the functional outcomes, with difficulties in at least one of the 6 ADL items and 5 IADL items defined as ADL/IADL limitation respectively. A logistic regression model was used to estimate the associations. RESULTS A total of 666 participants who were newly diagnosed with stroke during the 2018 wave were included. 234 (35.1%) participants were classified as non-frail, 380 (57.1%) participants were classified as prefrail, and 52 (7.8%) participants were classified as frail. Pre-stroke frailty was significantly associated with ADL and IADL limitations post stroke. Additional significant variables with ADL limitation were age, female and more comorbidities. Additional significant variables with IADL limitation were age, female, married or cohabitating, more comorbidities and pre-stroke lower global cognitive score. CONCLUSION Frailty status was associated with ADL and IADL limitations after stroke. A more comprehensive assessment of frailty in older people may help to identify those with most significant risk for declining functional capacities after stroke and to develop appropriate intervention strategies.
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Affiliation(s)
- Qi Zhang
- Doctor of Occupational Therapy (OTD), College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, China.
| | - Xi Gao
- Master of Education, Department of Exercise Sciences, The University of Auckland, New Zealand.
| | - Jia Huang
- College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, China.
| | - Qiurong Xie
- Master of Rehabilitation Science, College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, China.
| | - Yanxin Zhang
- Department of Exercise Sciences, The University of Auckland, Auckland 1142, New Zealand.
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23
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Koo AB, Elsamadicy AA, Renedo D, Matouk C. Response to letter to the Editor on 'Utility of the Hospital Frailty Risk Score in patients undergoing endovascular treatment for ruptured aneurysms'. J Neurointerv Surg 2023; 15:307-308. [PMID: 36319084 DOI: 10.1136/jnis-2022-019708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniela Renedo
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
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24
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Koo AB, Elsamadicy AA, Renedo D, Sarkozy M, Sherman J, Reeves BC, Havlik J, Antonios J, Sujijantarat N, Hebert R, Malhotra A, Matouk C. Higher Hospital Frailty Risk Score is associated with increased complications and healthcare resource utilization after endovascular treatment of ruptured intracranial aneurysms. J Neurointerv Surg 2023; 15:255-261. [PMID: 35292571 PMCID: PMC8931798 DOI: 10.1136/neurintsurg-2021-018484] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/15/2022] [Indexed: 12/29/2022]
Abstract
AIM To use the Hospital Frailty Risk Score (HFRS) to investigate the impact of frailty on complication rates and healthcare resource utilization in patients who underwent endovascular treatment of ruptured intracranial aneurysms (IAs). METHODS A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. All adult patients (≥18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM codes. Patients were categorized into frailty cohorts: low (HFRS <5), intermediate (HFRS 5-15) and high (HFRS >15). Patient demographics, adverse events, length of stay (LOS), discharge disposition, and total cost of admission were assessed. Multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, increased cost, and non-routine discharge. RESULTS Of the 33 840 patients identified, 7940 (23.5%) were found to be low, 20 075 (59.3%) intermediate and 5825 (17.2%) high frailty by HFRS criteria. The rate of encountering any adverse event was significantly greater in the higher frailty cohorts (low: 59.9%; intermediate: 92.4%; high: 99.2%, p<0.001). There was a stepwise increase in mean LOS (low: 11.7±8.2 days; intermediate: 18.7±14.1 days; high: 26.6±20.1 days, p<0.001), mean total hospital cost (low: $62 888±37 757; intermediate: $99 670±63 446; high: $134 937±80 331, p<0.001), and non-routine discharge (low: 17.3%; intermediate: 44.4%; high: 69.4%, p<0.001) with increasing frailty. On multivariate regression analysis, a similar stepwise impact was found in prolonged LOS (intermediate: OR 2.38, p<0.001; high: OR 4.49, p<0.001)], total hospital cost (intermediate: OR 2.15, p<0.001; high: OR 3.62, p<0.001), and non-routine discharge (intermediate: OR 2.13, p<0.001; high: OR 4.17, p<0.001). CONCLUSIONS Our study found that greater frailty as defined by the HFRS was associated with increased complications, LOS, total costs, and non-routine discharge.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniela Renedo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Josiah Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joseph Antonios
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nanthiya Sujijantarat
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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25
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Koo AB, Elsamadicy AA, Matouk CC. In Reply to the Letter to Editor Regarding "Hospital Frailty Risk Score Predicts Adverse Events and Readmission Following Ventriculoperitoneal Shunt Surgery for Normal Pressure Hydrocephalus". World Neurosurg 2023; 169:124. [PMID: 36585096 DOI: 10.1016/j.wneu.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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Dalli LL, Olaiya MT, Kim J, Andrew NE, Cadilhac DA, Ung D, Lindley RI, Sanfilippo FM, Thrift AG, Nelson MR, Gall SL, Kilkenny MF. Antihypertensive Medication Adherence and the Risk of Vascular Events and Falls After Stroke: A Real-World Effectiveness Study Using Linked Registry Data. Hypertension 2023; 80:182-191. [PMID: 36330805 DOI: 10.1161/hypertensionaha.122.19883] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Real-world evidence is limited on whether antihypertensive medications help avert major adverse cardiovascular events (MACE) after stroke without increasing the risk of falls. We investigated the association of adherence to antihypertensive medications on the incidence of MACE and falls requiring hospitalization after stroke. METHODS A retrospective cohort study of adults who were newly dispensed antihypertensive medications after an acute stroke (Australian Stroke Clinical Registry 2012-2016; Queensland and Victoria). Pharmaceutical dispensing records were used to determine medication adherence according to the proportion of days covered in the first 6 months poststroke. Outcomes between 6 and 18 months postdischarge included: (i) MACE, a composite outcome of all-cause death, recurrent stroke or acute coronary syndrome; and (ii) falls requiring hospitalization. Estimates were derived using Cox models, adjusted for >30 confounders using inverse probability treatment weights. RESULTS Among 4076 eligible participants (median age 68 years; 37% women), 55% had a proportion of days covered ≥80% within 6 months postdischarge. In the subsequent 12 months, 360 (9%) participants experienced a MACE and 337 (8%) experienced a fall requiring hospitalization. After achieving balance between groups, participants with a proportion of days covered ≥80% had a reduced risk of MACE (hazard ratio: 0.68; 95% CI: 0.54-0.84) and falls requiring hospitalization (subdistribution hazard ratio: 0.78; 95% CI: 0.62-0.98) than those with a proportion of days covered <80%. CONCLUSIONS High adherence to antihypertensive medications within 6 months poststroke was associated with reduced risks of both MACE and falls requiring hospitalization. Patients should be encouraged to adhere to their antihypertensive medications to maximize poststroke outcomes.
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Affiliation(s)
- Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.)
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.)
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia (N.E.A., D.U.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - David Ung
- Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia (N.E.A., D.U.)
| | - Richard I Lindley
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia (R.I.L.)
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia (F.M.S.)
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.)
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia (M.R.N., S.L.G.)
| | - Seana L Gall
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia (M.R.N., S.L.G.)
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
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Huang YN, Yan FH, Wang XY, Chen XL, Chong HY, Su WL, Chen YR, Han L, Ma YX. Prevalence and Risk Factors of Frailty in Stroke Patients: A Meta-Analysis and Systematic Review. J Nutr Health Aging 2023; 27:96-102. [PMID: 36806864 DOI: 10.1007/s12603-023-1879-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Summarize the existing evidence regarding the prevalence and risk factors of frailty in stroke patients. DESIGN A meta-analysis and systematic review. PARTICIPANTS Stroke patients in hospitals or communities. METHODS We undertook a systematic review and meta-analysis using articles available in 8 databases, including PubMed, The Cochrane Library, Web of Science, Embase, Chinese Biomedical Database (CBM), China National Knowledge Infrastructure Database (CNKI), Wanfang Database, and Weipu Database (VIP) from January 1990 to April 2022. Studies were quality rated using the Newcastle-Ottawa Scale and Agency for Healthcare Research and Quality tool. RESULTS A total of 24 studies involving 30,423 participants were identified. The prevalence of frailty and pre-frailty in stroke patients was 27% (95%CI: 0.23-0.31) and 47.9% (95%CI: 0.43-0.53). Female gender (OR = 1.76, 95%CI: 1.63-1.91), advanced age (MD = 6.73, 95%CI: 3.55-9.91), diabetes (OR = 1.34, 95%CI: 1.06-1.69), hyperlipidemia (OR = 1.46, 95%CI: 1.04-2.04), atrial fibrillation (OR = 1.36, 95%CI: 1.01-1.82), National Institutes of Stroke Scale (NIHSS) admission scores (MD = 2.27, 95%CI: 1.72-2.81) were risk factors of frailty in stroke patients. CONCLUSIONS Frailty was more prevalent in stroke patients. Female gender, advanced age, diabetes, hyperlipidemia, atrial fibrillation, and National Institutes of Stroke Scale (NIHSS) admission scores were identified as risk factors for frailty in stroke patients. In the future, medical staff should pay attention to the early screening of frailty in high-risk groups and provide information on its prevention.
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Affiliation(s)
- Y N Huang
- Yuxia Ma, Lin Han, Lanzhou University, China ,
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28
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Impact of Frailty Risk on Adverse Outcomes after Traumatic Brain Injury: A Historical Cohort Study. J Clin Med 2022; 11:jcm11237064. [PMID: 36498637 PMCID: PMC9735826 DOI: 10.3390/jcm11237064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/23/2022] [Accepted: 11/27/2022] [Indexed: 12/02/2022] Open
Abstract
We evaluated the utility of the Hospital Frailty Risk Score (HFRS) as a predictor of adverse events after hospitalization in a retrospective analysis of traumatic brain injury (TBI). This historical cohort study analyzed the data of patients hospitalized with TBI between April 2014 and August 2020 who were registered in the JMDC database. We used HFRS to classify the patients into the low- (HFRS < 5), intermediate- (HFRS5-15), and high- (HFRS > 15)-frailty risk groups. Outcomes were the length of hospital stay, the number of patients with Barthel Index score ≥ 95 on, Barthel Index gain, and in-hospital death. We used logistic and linear regression analyses to estimate the association between HFRS and outcome in TBI. We included 18,065 patients with TBI (mean age: 71.8 years). Among these patients, 10,139 (56.1%) were in the low-frailty risk group, 7388 (40.9%) were in the intermediate-frailty risk group, and 538 (3.0%) were in the high-frailty risk group. The intermediate- and high-frailty risk groups were characterized by longer hospital stays than the low-frailty risk group (intermediate-frailty risk group: coefficient 1.952, 95%; confidence interval (CI): 1.117−2.786; high-frailty risk group: coefficient 5.770; 95% CI: 3.160−8.379). The intermediate- and high-frailty risk groups were negatively associated with a Barthel Index score ≥ 95 on discharge (intermediate-frailty risk group: odds ratio 0.645; 95% CI: 0.595−0.699; high-frailty risk group: odds ratio 0.221; 95% CI: 0.157−0.311) and Barthel Index gain (intermediate-frailty risk group: coefficient −4.868, 95% CI: −5.599−−3.773; high-frailty risk group: coefficient −19.596, 95% CI: −22.242−−16.714). The intermediate- and high-frailty risk groups were not associated with in-hospital deaths (intermediate-frailty risk group: odds ratio 0.901; 95% CI: 0.766−1.061; high-frailty risk group: odds ratio 0.707; 95% CI: 0.459−1.091). We found that HFRS could predict adverse outcomes during hospitalization in TBI patients.
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Park DY, Hanna JM, Kadian S, Kadian M, Jones WS, Damluji AA, Kochar A, Curtis JP, Nanna MG. In-hospital outcomes and readmission in older adults treated with percutaneous coronary intervention for stable ischemic heart disease. J Geriatr Cardiol 2022; 19:631-642. [PMID: 36284680 PMCID: PMC9548058 DOI: 10.11909/j.issn.1671-5411.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) in older adults requires a meticulous assessment of procedural risks and benefits, but contemporary data on outcomes in this population is lacking. Therefore, we examined the risk of near-term readmission, bleeding, and mortality in high-risk cohort of older adults undergoing inpatient PCI for SIHD. METHODS We analyzed the National Readmissions Database from 2017 to 2018 to identify index hospitalizations in which PCI was performed for SIHD. Patients were stratified into those ≥ 75 years old (older adults) and those < 75 years old. The primary outcome was 90-day readmission. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and total hospital charge. RESULTS A total of 74,516 patients underwent inpatient PCI for SIHD, of whom 24,075 were older adults. Older adult patients had higher odds of in-hospital mortality (OR = 2.00, 95% CI: 1.68-2.38), intracranial hemorrhage (OR = 2.03, 95% CI: 1.24-3.34), and gastrointestinal hemorrhage (OR = 1.72, 95% CI: 1.43-2.07) during index hospitalization, with longer LOS and in-hospital charge. Older adults also experienced a higher hazard of 90-day readmission for any cause (HR = 1.61, 95% CI: 1.57-1.66) and cardiovascular causes (HR = 1.84, 95% CI: 1.77-1.91). CONCLUSION Older adults undergoing inpatient PCI for SIHD were at increased risk for in-hospital mortality, periprocedural morbidities, higher cost, and readmissions compared with younger adults. Understanding these differences may improve shared decision-making for patients with SIHD being considered for PCI.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Jonathan M. Hanna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | - W. Schuyler Jones
- Section of Interventional Cardiology, Duke University Health System, Durham, NC, USA
| | - Abdulla Al Damluji
- Section of Interventional Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Ajar Kochar
- Section of Interventional Cardiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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30
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Liu W, Zhang L, Fang H, Gao Y, Liu K, Li S, Liu H, Wang X, Liu C, Song B, Xia Z, Xu Y. Genetically predicted frailty index and risk of stroke and Alzheimer's disease. Eur J Neurol 2022; 29:1913-1921. [PMID: 35318774 DOI: 10.1111/ene.15332] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have reported the association between frailty and stroke or Alzheimer's disease (AD). However, the causality remains unclear. The aim of the present study was to evaluate whether genetically predicted frailty is associated with the risk of stroke or AD by a Mendelian randomization (MR) study. METHODS Genetic variants associated with the frailty index (FI) were obtained from a large genome-wide association study (GWAS). Summary-level data for stroke and AD were adopted from the corresponding large GWAS of individuals of European ancestry. The inverse variance weighted method was used for estimating causal effects. Multivariable analysis was performed for further adjustment. RESULTS The present MR study indicated a suggestive association between genetically predicted FI and a higher risk of any stroke (odds ratio 1.360, 95% confidence interval 1.006-1.838, p = 0.046). Regarding the subtypes of stroke, genetically predicted FI was associated with a higher risk of large artery atherosclerosis stroke (LAS) (odds ratio 2.487, 95% confidence interval 1.282-4.826, p = 0.007). No causal links were identified between genetically predicted FI and any ischaemic stroke, intracranial haemorrhage, cardioembolic stroke, small artery stroke, AD or AD-by-proxy. Multivariable MR analysis indicated that the association of genetically predicted FI with LAS was attenuated after adjustment for inflammatory bowel disease (p = 0.114). CONCLUSIONS The MR study suggested that genetically predicted FI may be associated with an increased risk of any stroke. Subgroup analysis indicated a suggestive association between genetically predicted FI and the risk of LAS. The underlying mechanisms need further investigation.
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Affiliation(s)
- Weishi Liu
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Systems Biology Laboratories, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Luyang Zhang
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Fang
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan Gao
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Liu
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shen Li
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Systems Biology Laboratories, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbing Liu
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Systems Biology Laboratories, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Wang
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Systems Biology Laboratories, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chen Liu
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Systems Biology Laboratories, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo Song
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zongping Xia
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Clinical Systems Biology Laboratories, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuming Xu
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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31
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Ushida K, Shimizu A, Hori S, Yamamoto Y, Momosaki R. Hospital Frailty Risk Score Predicts Outcomes in Chronic Obstructive Pulmonary Disease Exacerbations. Arch Gerontol Geriatr 2022; 100:104658. [PMID: 35190332 DOI: 10.1016/j.archger.2022.104658] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) are at high risk for frailty and prone to complications after admission for an acute exacerbation. We aim to investigate the association between frailty risk and functional outcomes in patients with acute exacerbations of COPD, using a nationwide database. METHODS This retrospective cohort study included patients with acute exacerbations of COPD who were admitted by ambulance. We assessed frailty using the Hospital Frailty Risk Score (HFRS) and compared the outcomes between low frailty risk (HFRS < 5) and frailty at risk (HFRS ≥ 5) groups. The primary outcome was prolonged hospitalization (≥30 days). The secondary outcomes were in-hospital mortality, readmission (≤90 days), poor activities of daily living (ADL) at discharge, and difficulty in returning home. RESULTS There were 3,396 eligible patients (mean age, 75.9 ± 11.2 years; 20.4% female). The rate of frailty at risk patients was 14.0%. Frailty at risk patients were significantly higher rates of prolonged hospitalization (32.9% vs. 17.5%), more in-hospital mortality (16.4% vs. 12.5%), more difficulty in returning home (34.6% vs. 22.9%), and poorer ADL at discharge (8.7% vs. 12.4%) than those of low frailty risk. Multivariate analysis with adjusted covariates showed that HFRS was independently associated with prolonged hospitalization (odds ratio, 2.0; 95% confidence interval, 1.4-2.9). CONCLUSIONS HFRS can be used to predict the outcome of patients with acute exacerbations of COPD. This finding supports the validity of using the HFRS in clinical practice with patients with acute exacerbations of COPD.
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Affiliation(s)
- Kenta Ushida
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu, 514-8507, Japan.
| | - Akio Shimizu
- Department of Nutrition, Hamamatsu City Rehabilitation Hospital, Hamamatsu, 443-8127, Japan
| | - Shinsuke Hori
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu, 514-8507, Japan
| | - Yoshinori Yamamoto
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu, 514-8507, Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine, Tsu, 514-8507, Japan
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Tan BYQ, Ho JSY, Leow AS, Chia MLJ, Sia CH, Koh YY, Seetharaman SK, Yang C, Gopinathan A, Teoh HL, Sharma VK, Seet RCS, Chan BPL, Yeo LLL, Tan LF. Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients. Age Ageing 2022; 51:6575882. [PMID: 35486669 DOI: 10.1093/ageing/afac096] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT). OBJECTIVE we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years. METHODS in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1-3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation. RESULTS a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04-2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002). CONCLUSIONS frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.
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Affiliation(s)
- Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jamie S Y Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, UK
| | - Aloysius S Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Magdalene L J Chia
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ching Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ying Ying Koh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Cunli Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Raymond C S Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Li Feng Tan
- Healthy Ageing Programme, Department of Geriatric Medicine, Alexandra Hospital, Singapore, Singapore
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The Allure of Big Data to Improve Stroke Outcomes: Review of Current Literature. Curr Neurol Neurosci Rep 2022; 22:151-160. [PMID: 35274192 PMCID: PMC8913242 DOI: 10.1007/s11910-022-01180-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To critically appraise literature on recent advances and methods using "big data" to evaluate stroke outcomes and associated factors. RECENT FINDINGS Recent big data studies provided new evidence on the incidence of stroke outcomes, and important emerging predictors of these outcomes. Main highlights included the identification of COVID-19 infection and exposure to a low-dose particulate matter as emerging predictors of mortality post-stroke. Demographic (age, sex) and geographical (rural vs. urban) disparities in outcomes were also identified. There was a surge in methodological (e.g., machine learning and validation) studies aimed at maximizing the efficiency of big data for improving the prediction of stroke outcomes. However, considerable delays remain between data generation and publication. Big data are driving rapid innovations in research of stroke outcomes, generating novel evidence for bridging practice gaps. Opportunity exists to harness big data to drive real-time improvements in stroke outcomes.
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Burton JK, Stewart J, Blair M, Oxley S, Wass A, Taylor-Rowan M, Quinn TJ. Prevalence and implications of frailty in acute stroke: systematic review & meta-analysis. Age Ageing 2022; 51:afac064. [PMID: 35352795 PMCID: PMC9037368 DOI: 10.1093/ageing/afac064] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/03/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND frailty is common in older adults and associated with poor outcomes following illness. Although stroke is predominantly a disease of older people, our knowledge of frailty in stroke is limited. We aimed to collate the literature on acute stroke and frailty to estimate the prevalence of pre-stroke frailty and its associations with outcomes. METHODS paired researchers searched multidisciplinary electronic databases for papers describing frailty and acute stroke. We assessed risk of bias using Newcastle-Ottawa tools appropriate to study design. We created summary estimates of pre-stroke frailty using random effects models. We collated whether studies reported significant positive associations between frailty and clinical outcomes in adjusted models. RESULTS we included 14 studies (n = 27,210 participants). Seven studies (n = 8,840) used a frailty index approach, four studies (n = 14,924) used Hospital Frailty Risk Scores. Pooled prevalence of pre-stroke frailty was 24.6% (95% confidence interval, CI: 16.2-33.1%; low quality evidence, downgraded due to heterogeneity, bias). Combining frailty and pre-frailty (nine studies, n = 23,827), prevalence of any frailty syndrome was 66.8% (95%CI: 49.9-83.7%). Seven studies were at risk of bias, from participant selection or method of frailty assessment. Pre-stroke frailty was associated with all adverse outcomes assessed, including longer-term mortality (positive association in 6 of 6 studies reporting this outcome; odds ratio: 3.75 [95%CI: 2.41-5.70]), length of admission (3 of 4 studies) and disability (4 of 6 studies). CONCLUSIONS despite substantial heterogeneity, whichever way it is measured, frailty is common in patients presenting with acute stroke and associated with poor outcomes. This has implications for the design of stroke services and pathways.
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Affiliation(s)
- Jennifer K Burton
- Institute of Cardiovascular and Medical Sciences, University of
Glasgow, Glasgow, UK
| | - Jennifer Stewart
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde,
Glasgow, UK
| | - Mairi Blair
- Queen Elizabeth University Hospital, NHS Greater Glasgow and
Clyde, Glasgow, UK
| | - Sinead Oxley
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde,
Glasgow, UK
| | - Amy Wass
- Forth Valley Royal Hospital, NHS Forth Valley, Larbert,
UK
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of
Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of
Glasgow, Glasgow, UK
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35
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Pilotto A, Brass C, Fassbender K, Merzou F, Morotti A, Kämpfer N, Siniscalchi A, Padovani A, Lochner P. Premorbid frailty predicts short- and long-term outcomes of reperfusion treatment in acute stroke. J Neurol 2022; 269:3338-3342. [PMID: 35039903 DOI: 10.1007/s00415-022-10966-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Frailty is the most important short- and long-term predictor of disability in the elderly and, thus, might influence the clinical outcome of acute treatment of stroke. OBJECTIVE To evaluate whether frailty predicts short- and long-term all-cause mortality and neurological recovery in elderly patients who underwent reperfusion acute treatment of stroke. METHODS The study included consecutive patients older than 65 years who underwent reperfusion treatment in a single stroke unit from 2015 to 2016. Predictors of stroke outcomes were assessed including demographics, baseline NIHSS, time to needle, treatment and medical complications. Premorbid frailty was assessed with a comprehensive geriatric assessment including functional, nutritional, cognitive, social and comorbidities status. At three and twelve months, all-cause death and clinical recovery (using modified Rankin scale, mRS) were evaluated. RESULTS One-hundred and two patients who underwent acute reperfusion treatment for stroke entered the study (mean age 77.5, 65-94 years). Frailty was diagnosed in 32 out of 102 patients and associated with older age (p = 0.001) but no differences in baseline NIHSS score, vascular risk profile or treatment management strategy. Frailty status was associated with worse improvement at 24 h and higher in-hospital mortality. At follow-up, frail patients showed poorer survival at 3 (25% vs 3%, p = 0.008) and 12 (38% vs 7%, p = 0.001) months. Frailty was the best predictor of neurological recovery at one year follow-up (mRS 3.2 ± 1.9 vs 1.9 ± 1.9). DISCUSSION Frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. Larger longitudinal studies are, thus, warranted to evaluate the risk-benefit of reperfusion treatment in the growing elderly frail population.
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Affiliation(s)
- Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, P.zale Spedali Civili, 1-25213, Brescia, Italy. .,FERB Onlus, Ospedale S. Isidoro, Trescore Balneario, Bergamo, Italy.
| | - Cora Brass
- Department of Neurology, Kreisklinikum Siegen, Siegen, Germany
| | - Klaus Fassbender
- Department of Neurology, University of the Saarland, Homburg, Saar, Germany
| | - Fatma Merzou
- Department of Neurology, University of the Saarland, Homburg, Saar, Germany
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, P.zale Spedali Civili, 1-25213, Brescia, Italy
| | - Niklas Kämpfer
- Department of Neurology, University of the Saarland, Homburg, Saar, Germany
| | - Antonio Siniscalchi
- Department of Neurology and Stroke Unit, Annunziata Hospital of Cosenza, Cosenza, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, P.zale Spedali Civili, 1-25213, Brescia, Italy
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