The Fine Line Between Simplicity and Oversimplification: Comparing the Risk Analysis Index and 5-Factor Modified Frailty Index as Frailty Assessment Tools

Discriminatory Value of the Risk Analysis Index Versus the 5-Factor Modified Frailty Index for Major Outcome Measures in Degenerative Cervical Myelopathy

Study DesignObservational Retrospective Cohort Study.ObjectivesTo compare the discriminatory abilities of the Revised Risk Analysis Index (RAI-Rev) and the 5-Factor Modified Frailty Index (mFI-5) to predict major postoperative outcomes in DCM patients overall, and by anterior (ADF) or posterior (PDF) approaches for decompression and fusion.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DCM patients undergoing ADF or PDF from 2015-2020. Logistic regression and Receiver Operating Characteristic analysis were used to compare the predictive and discriminatory value of mFI-5 and RAI-Rev for 30-day outcomes.Results18,138 DCM patients were included (median age: 61 years). Both RAI-Rev and mFI-5 predicted 30-day outcomes; however, increasing frailty as measured by RAI-Rev demonstrated greater odds ratios. RAI-rev demonstrated superior discrimination for non-fatal adverse outcomes, notably non-home discharge (NHD) [C-statistic 0.72 (95% CI 0.71-0.73, P < 0.001)], and for all non-fatal measures except major complications (P < 0.05). Sub-analysis by approach showed frailty had greater predictive accuracy for adverse outcomes in ADF compared to PDF.ConclusionsThe RAI-Rev demonstrated superior discrimination predicting non-fatal outcomes following DCM when compared to the mFI-5, with equivalent mortality prediction. Further, frailty plays a stronger role in predicting mortality and morbidity in ADF compared to frailty's impact on predicting outcomes with PDF. This finding demonstrates the utility of the RAI-Rev in preoperative risk stratification with an increasingly frail patient population and provides initial evidence for selecting posterior approaches for DCM patients as frailty increases.

Orthopedic frailty risk stratification (OFRS): a systematic review of the frailty indices predicting adverse outcomes in orthopedics

BACKGROUND

With a growing number of elderly patients requiring elective and non-elective procedures, frailty-based preoperative risk stratification is an emerging tool in orthopedic surgery to minimize adverse postoperative outcomes. This paper sought to understand the current literature regarding preoperative Orthopedic Frailty Risk Stratification (OFRS) and describe the disparate frailty indices and their capabilities for discrimination in predicting adverse postoperative outcomes.

METHODS

A literature search was conducted in Pubmed, Cochrane, and Scopus for articles published during or prior to February 2024 assessing frailty following surgery for orthopedic pathologies. Qualitative variables including study characteristics and application of frailty were collected and synthesized. Quantitative meta-analysis was performed for pooled odds ratio (OR) and area under the curve (AUC) of frailty for mortality and complications. All methods were performed in accordance with PRISMA guidelines.

RESULTS

Of the 81 included articles, over half (52%) addressed traumatic orthopedic pathologies with traumatic hip fractures being the most studied in the OFRS (25 studies). Less common categories included oncology, sports, and foot/ankle. Functional status and independence were the most common frailty domain (25, 96.2%) and component across scales (20, 76.9%), respectively. The 5-Item Modified Frailty Index (mFI-5) was the most common frailty index (28 publications). Meta-analysis demonstrated increasing frailty was an independent predictor of mortality (30-day OR: 2.89, 95% CI: 2.00-4.18; 1 year OR: 1.81, 95% CI: 1.48-2.22, p < 0.001), major complications (OR: 1.63, 95% CI: 1.10-2.41, p = 0.02), and Clavien-Dindo IV complications (OR: 3.26, 95% CI: 2.18-4.87, p < 0.001). Frailty had good discriminatory accuracy for predicting mortality at 30-days (AUC: 0.71, 95% CI: 0.68-0.74, p < 0.001), 3-months (OR: 0.75, 95% CI: 0.65-0.83, p < 0.001), and 1-year (OR:0.74, 95% CI: 0.73-0.75, p < 0.001).

CONCLUSIONS

The orthopedic surgery frailty literature is extremely heterogeneous, with disparate frailty scales implemented to measure varying outcomes across many orthopedic pathologies. Despite no consensus on exact scales or definitions, various frailty indices have predicted adverse outcomes.

Association Between Modified Frailty Index and Postoperative Outcomes of Cricopharyngeal Myotomy

OBJECTIVE

The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool previously validated in patients undergoing several surgical procedures. This study investigates the association between mFI-5 score and cricopharyngeal myotomy (CM) complications.

STUDY DESIGN

Retrospective database review.

SETTING

US hospitals.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent CM between 2005 and 2018. mFI-5 score was determined by assigning 1 point for comorbidities including: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent health status. Univariate and multivariable analyses were conducted to determine associations between mFI-5 score and postoperative complications.

RESULTS

A total of 1075 patients undergoing CMs were queried and stratified into the following groups: mFI = 0 (n = 412 [38.3%]), mFI = 1 (n = 452 [42.0%]), and mFI ≥ 2 (n = 211 [19.6%]). Univariate analysis showed association between higher mFI-5 scores with older age, higher American Society of Anesthesiologists Classification class, obesity, smoking, dyspnea, and systemic sepsis. Higher mFI-5 was associated with a greater proportion of cumulative surgical complications, cumulative medical complications, pneumonia, myocardial infarction, cumulative morbidity, readmissions, unplanned readmissions, and reoperations. Multivariable analyses found associations between greater mFI-5 score and cumulative morbidity (odds ratio [OR] = 1.95, confidence interval [CI]: 1.29-2.96, P = .002), any surgical complication (OR = 1.80, CI: 1.15-2.79, P = .010), readmission (OR = 1.81, CI: 1.01-3.26, P = .047), and reoperations (OR = 1.96, CI: 1.04-3.68, P = .037).

CONCLUSION

Evaluating mFI-5 can help assess the risk of postoperative complications for patients undergoing CM.

LEVEL OF EVIDENCE

Level 4.

Frailty Predicts 30-day mortality following major complications in neurosurgery patients: The risk analysis index has superior discrimination compared to modified frailty index-5 and increasing patient age

Background

Postoperative complications after cranial or spine surgery are prevalent, and frailty can be a key contributing patient factor. Therefore, we evaluated frailty's impact on 30-day mortality. We compared the discrimination for risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for predicting 30-day mortality.

Methods

Patients with major complications following neurosurgery procedures between 2012- 2020 in the ACS-NSQIP database were included. We employed receiver operating characteristic (ROC) curve and examined discrimination thresholds for RAI, mFI-5, and increasing patient age for 30-day mortality. Independent relationships were examined using multivariable analysis.

Results

There were 19,096 patients included in the study and in the ROC analysis for 30-day mortality, RAI showed superior discriminant validity threshold C-statistic 0.655 (95% CI: 0.644-0.666), compared to mFI-5 C-statistic 0.570 (95% CI 0.559-0.581), and increasing patient age C-statistic 0.607 (95% CI 0.595-0.619). When the patient population was divided into subsets based on the procedures type (spinal, cranial or other), spine procedures had the highest discriminant validity threshold for RAI (Cstatistic 0.717). Furthermore, there was a frailty risk tier dose response relationship with 30-day mortalityy (p<0.001).

Conclusion

When a major complication arises after neurosurgical procedures, frail patients have a higher likelihood of dying within 30 days than their non-frail counterparts. The RAI demonstrated a higher discriminant validity threshold than mFI-5 and increasing patient age, making it a more clinically relevant tool for identifying and stratifying patients by frailty risk tiers. These findings highlight the importance of initiatives geared toward optimizing frail patients, to mitigate long-term disability.

The Weight of Frailty in Neurosurgery Patients: Analyzing the Combined Effect of Frailty and Body Mass Index on 30-Day Postoperative Mortality

OBJECTIVE

There is a rising prevalence of overweight and obese persons in the US, and there is a paucity of information about the relationship between frailty and body mass index. Therefore, we examined discrimination thresholds and independent relationships of the risk analysis index (RAI), modified frailty index-5 (mFI-5), and increasing patient age in predicting 30-day postoperative mortality.

METHODS

This retrospective American College of Surgeons National Surgical Quality Improvement Program analysis compared all overweight or obese adult patients who underwent neurosurgery procedures between 2012 and 2020. We compared discrimination using receiver operating characteristic curve analysis for RAI, mFI-5, and increasing patient age. Furthermore, multivariable analyses, as well as subgroup analyses by procedure type i.e., spine, skull base, and other (vascular and functional) were performed, and reported as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We included 315,725/412,909 (76.5%) neurosurgery patients, with a median age of 59 years (interquartile range: 48-68), predominately White 76.7% and male 54.3%. Receiver operating characteristic analysis for 30-day postoperative mortality demonstrated a higher discriminatory threshold for RAI (C-statistic: 0.790, 95%CI: 0.782-0.800) compared to mFI-5 (C-statistic: 0.692, 95%CI: 0.620-0.638) and increasing patient age (C-statistic: 0.659, 95%CI: 0.650-0.668). Multivariable analyses showed a dose-dependent association and a larger magnitude of effect by RAI: frail patients OR: 11.82 (95%CI: 10.57-13.24), and very frail patients OR: 31.19 (95%CI: 24.87-39.12). A similar trend was observed in all subgroup analyses i.e., spine, skull base, and other (vascular and functional) procedures (P ≤ 0.001).

CONCLUSIONS

Increasing frailty was associated with a higher rate of 30-day postoperative mortality, with a dose-dependent effect. Furthermore, the RAI had a higher threshold for discrimination and larger effect sizes than mFI-5 and increasing patient age. These findings support RAI's use in preoperative assessments, as it has the potential to improve postoperative outcomes through targeted interventions.

Multiplicative effect of frailty and obesity on postoperative mortality following spine surgery: a deep dive into the frailty, obesity, and Clavien-Dindo dynamic

BACKGROUND/OBJECTIVES

Obesity is a global health challenge that affects a large proportion of adults worldwide. Obesity and frailty pose considerable health risks due to their potential to interact and amplify one another's negative effects. Therefore, we sought to compare the discriminatory thresholds of the risk analysis index (RAI), 5-factor modified frailty index (m-FI-5) and patient age for the primary endpoint of postoperative mortality.

SUBJECTS/METHODS

We included spine surgery patients ≥18 years old, from the American College of Surgeons National Quality Improvement program database from 2012-2020, that were classified as obese. We performed receiver operating characteristic curve analysis to compare the discrimination threshold of RAI, mFI-5, and patient age for postoperative mortality. Proportional hazards risk-adjusted regressions were performed, and Hazard ratios and corresponding 95% Confidence intervals (CI) are reported.

RESULTS

Overall, there were 149 163 patients evaluated, and in the ROC analysis for postoperative mortality, RAI showed superior discrimination C-statistic 0.793 (95%CI: 0.773-0.813), compared to mFI-5 C-statistic 0.671 (95%CI 0.650-0.691), and patient age C-statistic 0.686 (95%CI 0.666-0.707). Risk-adjusted analyses were performed, and the RAI had a stepwise increasing effect size across frailty strata: typical patients HR 2.55 (95%CI 2.03-3.19), frail patients HR 3.48 (95%CI 2.49-4.86), and very frail patients HR 4.90 (95%CI 2.87-8.37). We found increasing postoperative mortality effect sizes within Clavein-Dindo complication strata, consistent across obesity categories, exponentially increasing with frailty, and multiplicatively enhanced within CD, frailty and obesity strata.

CONCLUSION

In this study of 149 163 patients classified as obese and undergoing spine procedures in an international prospective surgical database, the RAI demonstrated superior discrimination compared to the mFI-5 and patient age in predicting postoperative mortality risk. The deleterious effects of frailty and obesity were synergistic as their combined effect predicted worse outcomes.

The risk analysis index demonstrates exceptional discrimination in predicting frailty's impact on neurosurgical length of stay quality metrics

BACKGROUND

Quality measures determine reimbursement rates and penalties in value-based payment models. Frailty impacts these quality metrics across surgical specialties. We compared the discriminatory thresholds for the risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for the outcomes of extended length of stay (LOS [eLOS]), prolonged LOS within 30 days (pLOS), and protracted LOS (LOS > 30).

METHODS

Patients ≥18 years old who underwent neurosurgical procedures between 2012 and 2020 were queried from the ACS-NSQIP. We performed receiver operating characteristic analysis, and multivariable analyses to examine discriminatory thresholds and identify independent associations.

RESULTS

There were 411,605 patients included, with a median age of 59 years (IQR, 48-69), 52.2% male patients, and a white majority 75.2%. For eLOS: RAI C-statistic 0.653 (95% CI: 0.652-0.655), versus mFI-5 C-statistic 0.552 (95% CI: 0.550-0.554) and increasing patient age C-statistic 0.573 (95% CI: 0.571-0.575). Similar trends were observed for pLOS- RAI: 0.718, mFI-5: 0.568, increasing patient age: 0.559, and for LOS>30- RAI: 0.714, mFI-5: 0.548, and increasing patient age: 0.506. Patients with major complications had eLOS 10.1%, pLOS 26.5%, and LOS >30 45.5%. RAI showed a larger effect for all three outcomes, and major complications in multivariable analyses.

CONCLUSION

Increasing frailty was associated with three key quality metrics that is, eLOS, pLOS, LOS > 30 after neurosurgical procedures. The RAI demonstrated a higher discriminating threshold compared to both mFI-5 and increasing patient age. Preoperative frailty screening may improve quality metrics through risk mitigation strategies and better preoperative communication with patients and their families.