Risk Analysis Index and 30-Day Mortality after Brain Tumor Resection: A Multicenter Frailty Analysis of 31,776 Patients from 2012 to 2020

Introduction  The aim of this study was to evaluate the discriminative accuracy of the preoperative Risk Analysis Index (RAI) frailty score for prediction of mortality or transition to hospice within 30 days of brain tumor resection (BTR) in a large multicenter, international, prospective database. Methods  Records of BTR patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program (2012-2020) database. The relationship between the RAI frailty scale and the primary end point (mortality or discharge to hospice within 30 days of surgery) was assessed using linear-by-linear proportional trend tests, logistic regression, and receiver operating characteristic (ROC) curve analysis (area under the curve as C-statistic). Results  Patients with BTR ( N  = 31,776) were stratified by RAI frailty tier: 16,800 robust (52.8%), 7,646 normal (24.1%), 6,593 frail (20.7%), and 737 severely frail (2.3%). The mortality/hospice rate was 2.5% ( n  = 803) and was positively associated with increasing RAI tier: robust (0.9%), normal (3.3%), frail (4.6%), and severely frail (14.2%) ( p  < 0.001). Isolated RAI was a robust discriminatory of primary end point in ROC curve analysis in the overall BTR cohort (C-statistic: 0.74; 95% confidence interval [CI]: 0.72-0.76) as well as the malignant (C-statistic: 0.74; 95% CI: 0. 67-0.80) and benign (C-statistic: 0.71; 95% CI: 0.70-0.73) tumor subsets (all p  < 0.001). RAI score had statistically significantly better performance compared with the 5-factor modified frailty index and chronological age (both p  < 0.0001). Conclusions  RAI frailty score predicts 30-day mortality after BTR and may be translated to the bedside with a user-friendly calculator ( https://nsgyfrailtyoutcomeslab.shinyapps.io/braintumormortalityRAIcalc/ ). The findings hope to augment the informed consent and surgical decision-making process in this patient population and provide an example for future study designs.

Short-term mortality and revisions to promote maturation after arteriovenous fistula creation

OBJECTIVE

Arteriovenous fistula (AVF) for hemodialysis access is traditionally considered superior to grafts due to infection resistance and purported improved patency. However, challenges to AVF maturation and limited patient survival may reduce AVF benefits. The objective of this study is to identify factors associated with risk of AVF requiring revision before maturation and/or mortality within 2 years of creation.

METHODS

We performed a retrospective review of 250 AVFs created between May 2017 and November 2020 at a single institution. Maturation was defined as the date the surgeon deemed the AVF ready for use or the patient successfully used the AVF for dialysis. The Risk Analysis Index was used to calculate frailty. The primary outcome was a composite of endovascular/surgical revision to promote maturation and/or mortality within 2 years of AVF creation (REVDEAD). The primary outcome was categorized as met if the patient required a revision to promote maturation or if the patient experienced mortality within 2 years of AVF creation, or if both occurred. REVDEAD was compared with those who did not meet the primary outcome and will be referred to as NOREVDEAD.

RESULTS

Survival at 2 years after AVF creation was 82%, and 54 (22%) patients underwent AVF revision. Of those, 31 (59%) patients progressed to AVF maturation. Of the 250 AVFs, 91 (36%) met the primary outcome of REVDEAD and 159 (64%) did not (NOREVDEAD). There was no difference between the REVDEAD and NOREVDEAD groups in age (P = .18), sex (P = .75), White race (P = .97), Hispanic ethnicity (P = .62), obesity (P = .76), coronary artery disease (P = .07), congestive heart failure (P = .29), diabetes mellitus (P = .78), chronic obstructive pulmonary disease (P = .10), dialysis status (P = .63), hypertension (P = .32), peripheral arterial disease (P = .34), or dysrhythmia (P = .13). There was no difference between the groups in the forearm vs the upper arm location of AVF (P = .42) or the vein diameter (P = .58). Forearm access, as opposed to upper arm AVF creation, was associated with higher rate of revision before maturation (P = .05). More patients in REVDEAD were frail or very frail (60% vs 48%, P = .05). Of the AVFs that matured, maturation required longer time in REVDEAD at 110.0 ± 9.1 days vs 78.8 ± 5.6 days (mean ± standard deviation) (P = .003). Adjusted for the vein diameter and the forearm vs the upper arm, frailty increased the odds of REVDEAD by 1.9 (95% confidence interval: 1.1, 3.3).

CONCLUSIONS

Frail patients who underwent AVF were significantly more likely to die within 2 years of AVF creation with no significant association between frailty and the need for revisions to promote maturation. Forearm AVFs were more likely to require revisions; in patients who are frail, with a high likelihood of 2-year mortality, graft may be more appropriate than AVF. If AVF is being considered in a frail patient, upper arm AVFs should be prioritized over forearm AVFs.

Risk Analysis Index as a preoperative frailty tool for elective ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus

OBJECTIVE

Idiopathic normal pressure hydrocephalus (iNPH) predominantly occurs in older patients, and ventriculoperitoneal shunt (VPS) placement is the definitive surgical treatment. VPS surgery carries significant postoperative complication rates, which may tip the risk/benefit balance of this treatment option for frail, or higher-risk, patients. In this study, the authors investigated the use of frailty scoring for preoperative risk stratification for adverse event prediction in iNPH patients who underwent elective VPS placement.

METHODS

The Nationwide Readmissions Database (NRD) was queried from 2018 to 2019 for iNPH patients aged ≥ 60 years who underwent VPS surgery. Risk Analysis Index (RAI) and modified 5-item Frailty Index (mFI-5) scores were calculated and RAI cross-tabulation was used to analyze trends in frailty scores by the following binary outcome measures: overall complications, nonhome discharge (NHD), extended length of stay (eLOS) (> 75th percentile), and mortality. Area under the receiver operating characteristic curve analysis was performed to assess the discriminatory accuracy of RAI and mFI-5 for primary outcomes.

RESULTS

A total of 9319 iNPH patients underwent VPS surgery, and there were 685 readmissions (7.4%), 593 perioperative complications (6.4%), and 94 deaths (1.0%). Increasing RAI score was significantly associated with increasing rates of postoperative complications: RAI scores 11-15, 5.4% (n = 80); 16-20, 5.6% (n = 291); 21-25, 7.6% (n = 166); and ≥ 26, 11.6% (n = 56). The discriminatory accuracy of RAI was statistically superior (DeLong test, p < 0.05) to mFI-5 for the primary endpoints of mortality, NHD, and eLOS. All RAI C-statistics were > 0.60 for mortality within 30 days (C-statistic = 0.69, 95% CI 0.68-0.70).

CONCLUSIONS

In a nationwide database analysis, increasing frailty, as measured by RAI, was associated with NHD, 30-day mortality, unplanned readmission, eLOS, and postoperative complications. Although the RAI outperformed the mFI-5, it is essential to account for the potentially reversible clinical issues related to the underlying disease process, as these factors may inflate frailty scores, assign undue risk, and diminish their utility. This knowledge may enhance provider understanding of the impact of frailty on postoperative outcomes for patients with iNPH, while highlighting the potential constraints associated with frailty assessment tools.

Prediction of 30-day and 1-year postoperative complications after balloon-assisted kyphoplasty in the elderly using the Risk Analysis Index

OBJECTIVE

Vertebral compression fracture (VCF) is the most prevalent fragility fracture. When conservative management fails, patients may undergo balloon-assisted kyphoplasty (BAK). In BAK, an expandable balloon preforms a cavity in the fractured vertebra before injection of bone cement. The aim of this study was to compare outcomes in patients stratified by age and frailty assessed by the Risk Analysis Index (RAI).

METHODS

A retrospective analysis of 334 BAK procedures (280 patients) for osteoporotic VCFs at a single institution was performed (2015-2022). Patients with at least 1 year of follow-up were eligible for inclusion. Patient demographics were recorded, including age, sex, BMI, RAI score, tobacco and steroid use, osteoporosis treatments, and bone density. Patients who underwent outpatient surgery were identified, and length of stay (LOS) was obtained for admitted patients. The rates of additional VCFs after kyphoplasty, 30-day and 1-year postoperative complications, and reoperation were identified.

RESULTS

The overall rates of additional VCFs, 30-day postoperative complications, 1-year postoperative complications, and reoperation were 16.2%, 5.1%, 12.0%, and 6.3%, respectively. Patients were stratified by age: nonelderly (< 80 years; 220 patients, 263 treated vertebrae) and elderly (≥ 80 years; 60 patients, 71 treated vertebrae). There were no differences in sex (p = 0.593), tobacco use (p = 0.973), chronic steroid use (p = 0.794), treatment for osteoporosis (p = 0.537), bone density (p = 0.056), outpatient procedure (p = 0.273), and inpatient LOS (p = 0.661) between both groups. There were also no differences in the development of additional VCFs (p = 0.862) at an adjacent level (p = 0.739) or remote level (p = 0.814), 30-day and 1-year postoperative complications (p = 0.794 and p = 0.560, respectively), and reoperation rates (p = 0.420). Patients were then analyzed by RAI: nonfrail (RAI score < 30; 203 patients, 243 treated vertebrae) and frail (RAI score ≥ 31; 77 patients, 91 treated vertebrae). There were no differences in tobacco use (p = 0.959), chronic steroid use (p = 0.658), treatment for osteoporosis (p = 0.560), bone density (p = 0.339), outpatient procedure (p = 0.241), inpatient LOS (p = 0.570), and development of additional VCFs (p = 0.773) at an adjacent level (p = 0.390) or remote level (p = 0.689). However, rates of 30-day and 1-year postoperative complications in frail patients more than doubled in comparison with nonfrail patients (p = 0.031 and p = 0.007, respectively), and frail patients trended toward reoperation (p = 0.097).

CONCLUSIONS

BAK is a safe treatment in the elderly, and age alone should not be used as an exclusion criterion during patient selection. Frailty, which can be assessed reliably using the RAI, may serve as a better predictor for postoperative complications and reoperation following BAK.

Preoperative frailty and 30-day mortality after resection of brain metastases: a multicenter surgical registry analysis of 11,038 patients

OBJECTIVE

Surgery plays a key role in the management of brain metastases. Stratifying surgical risk and individualizing treatment will help optimize outcomes because there is clinical equipoise between radiation and resection as treatment options for many patients. Here, the authors used a multicenter database to assess the prognostic utility of baseline frailty, calculated with the Risk Analysis Index (RAI), for prediction of mortality within 30 days after surgery for brain metastasis.

METHODS

The authors pooled patients who had been surgically treated for brain metastasis from the American College of Surgeons National Surgical Quality Improvement Program database (2012-2020). The authors studied the relationship between preoperative calculated RAI score and 30-day mortality after surgery for brain metastasis by using linear-by-linear proportional trend tests and binary logistic regression. The authors calculated C-statistics (with 95% CIs) in receiver operating characteristic (ROC) curve analysis to assess discriminative accuracy.

RESULTS

The authors identified 11,038 patients who underwent brain metastasis resection with a median (interquartile range) age of 62 (54-69) years. The authors categorized patients into four groups on the basis of RAI: robust (RAI 0-20), 8.1% of patients; normal (RAI 21-30), 9.2%; frail (RAI 31-40), 75%; and severely frail (RAI ≥ 41), 8.1%. The authors found a positive correlation between 30-day mortality and frailty. RAI demonstrated superior predictive discrimination for 30-day mortality as compared with the 5-factor modified frailty index (mFI-5) on ROC analysis (C-statistic 0.65, 95% CI 0.65-0.66).

CONCLUSIONS

The RAI frailty score accurately estimates 30-day mortality after brain metastasis resection and can be calculated online with an open-access software tool: https://nsgyfrailtyoutcomeslab.shinyapps.io/BrainMetsResection/. Accordingly, RAI can be utilized to measure surgical risk, guide treatment options, and optimize outcomes for patients with brain metastases. RAI has superior discrimination for predicting 30-day mortality compared with mFI-5.

Comparison of the Risk Analysis Index and the modified 5-factor frailty index in predicting 30-day morbidity and mortality after spine surgery

OBJECTIVE

Frailty's role in preoperative risk assessment in spine surgery has increased in association with the increasing size of the aging population. However, previous frailty assessment tools have significant limitations. The aim of this study was to compare the predictive ability of the Risk Analysis Index (RAI) with the 5-factor modified frailty index (mFI-5) for postoperative spine surgery morbidity and mortality.

METHODS

Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database for adults > 18 years who underwent spine surgery between 2015 and 2019. Multivariate modeling and receiver operating characteristic curve analysis, including area under the curve/C-statistic calculations, were performed to evaluate the comparative discriminative ability of RAI and mFI-5 on postoperative outcomes.

RESULTS

In a cohort of 292,225 spine surgery patients, multivariate modeling showed that increasing RAI scores, and not increasing mFI-5 scores, were independent predictors of increased postoperative mortality for the trauma, tumor, and infection subcohorts. In the overall spine cohort, both increasing RAI and increasing mFI-5 scores were associated with increased mortality, but C-statistics indicated that the RAI (C-statistic 0.802 [95% CI 0.800-0.803], p < 0.0001, DeLong test) had superior discrimination compared with the mFI-5 (C-statistic 0.677 [95% CI 0.675-0.679], p < 0.0001, DeLong test). In subgroup analyses, the RAI had superior discriminative ability to mFI-5 for mortality in the trauma and infection groups (p < 0.001 and p = 0.039, respectively).

CONCLUSIONS

The RAI demonstrates superior discrimination to the mFI-5 for predicting postoperative mortality and morbidity after spine surgery and the RAI maintains conceptual fidelity to the frailty phenotype. Patients with high RAI scores may benefit from knowing the possibility of increased surgical risk with potential spine surgery.

Preoperative Frailty Predicts Worse Outcomes after Microvascular Decompression for Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: A Multicenter Analysis of 1,473 Patients from a Prospective Surgical Registry

INTRODUCTION

Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (n = 1,211), hemifacial spasm (n = 236), or glossopharyngeal neuralgia (n = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis.

RESULTS

Patients undergoing MVD (N = 1,473) were stratified by RAI frailty bins: 71% with RAI 0-20, 28% with RAI 21-30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, p = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, p = 0.001), and AD (6.1% vs. 1.0%, p &lt; 0.001). The rate of primary endpoint was 2.4% (N = 36) and was positively associated with increasing frailty tier: 1.5% in 0-20, 5.8% in 21-30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74-0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61-0.66) (DeLong pairwise test, p = 0.003).

CONCLUSIONS

This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: <ext-link ext-link-type="uri" xlink:href="https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression" xmlns:xlink="http://www.w3.org/1999/xlink">https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression</ext-link>.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients

BACKGROUND

With an aging population, elderly patients with multiple comorbidities are more frequently undergoing spine surgery and may be at increased risk for complications. Objective measurement of frailty may predict the incidence of postoperative adverse events.

OBJECTIVE

To investigate the associations between preoperative frailty and postoperative spine surgery outcomes including mortality, length of stay, readmission, surgical site infection, and venous thromboembolic disease.

METHODS

As part of a system-wide quality improvement initiative, frailty assessment was added to the routine assessment of patients considering spine surgery beginning in July 2016. Frailty was assessed with the Risk Analysis Index (RAI), and patients were categorized as nonfrail (RAI 0-29) or prefrail/frail (RAI ≥ 30). Comparisons between nonfrail and prefrail/frail patients were analyzed using Fisher's exact test for categorical data or by Wilcoxon rank sum tests for continuous data.

RESULTS

From August 2016 through September 2018, 668 patients (age of 59.5 ± 13.3 yr) had a preoperative RAI score recorded and underwent scheduled spine surgery. Prefrail and frail patients suffered comparatively higher rates of mortality at 90 d (1.9% vs 0.2%, P < .05) and 1 yr (5.1% vs 1.2%, P < .01) from the procedure date. They also had longer in-hospital length of stay (LOS) (3.9 d ± 3.6 vs 3.1 d ± 2.8, P < .001) and higher rates of 60 d (14.6% vs 8.2%, P < .05) and 90 d (15.8% vs 9.8%, P < .05) readmissions.

CONCLUSION

Preoperative frailty, as measured by the RAI, was associated with an increased risk of readmission and 90-d and 1-yr mortality following spine surgery. The RAI can be used to stratify spine patients and inform preoperative surgical decision making.

Validation of the Risk Analysis Index for Evaluating Frailty in Ambulatory Patients

BACKGROUND

Frailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown.

OBJECTIVE

Validate the RAI in ambulatory patients.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy).

MAIN OUTCOMES AND MEASURES

All-cause 1-year mortality, assessed by stratified Cox proportional hazard models.

RESULTS

Of 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure.

CONCLUSION

RAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818-1824, 2020.

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

OBJECTIVE

Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database.

METHODS

Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.

RESULTS

A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001).

CONCLUSIONS

There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.