When we fail (to rescue) the frail

 

Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. Shah, R et al. JAMA Surg. 2018 Mar 21:e180214.

Background

Frailty syndromes affect a fifth of over 65 year-olds and prevalence increases with increasing age.  Frailty may characterised by insufficient physiological reserve to compensate for the effects of ‘health stressors’; or the accumulation of morbidity – multimorbidity has been shown to increase substantially with age.

Adverse postoperative outcomes are more common in frail patients, but early identification of frailty and augmented perioperative pathways of care may improve outcomes.  Global populations of over 65 year-olds are set to increase dramatically over the coming decades, so it’s vital that healthcare systems are prepared!

Question

What is the association of patient frailty with postoperative complications and failure to rescue after low-risk and high-risk inpatient surgery?

Methods

Materials: Retrospective analysis of the Veteran’s Association National Surgical Quality Improvement Program (VA-NSQIP) dataset.

Participants: Patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery between 1st January 2005 and 31st December 2012.

Analysis: Frailty was assessed using the Risk Analysis Index (RAI), and patients stratified into 5 groups.  Operative procedures were categorized as low mortality risk (=<1%) or high mortality risk (>1%) within the dataset.  Joint primary outcomes were number of postoperative complications and inpatient failure to rescue (deaths as a proportion of complications).  (Complications were classified as major or minor and 30-day mortality was also investigated).  Associations between RAI scores and number of postoperative complications (0, 1, 2, or 3 or more) and FTR were evaluated.

Results

984 550 patients were included, mean age 58 years (+/- 17.1), 56% women.

Both the incidence and absolute number of postoperative complications (both major and any) increased with increasing frailty category (RAI).  This was observed not only in what the authors term ‘high-risk’ surgery, but also after ‘low-risk’ procedures.  Incidence of 30-day mortality increased across frailty categories.  The authors state that frailty is directly associated with failure to rescue, independent of the observed association with complications.

Authors’ conclusions

Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic preoperative assessment of frailty may identify patients who would benefit from perioperative interventions designed to enhance physiological reserve.

Discussion

Demonstration of increased incidence of postoperative complications, morbidity and mortality with increasing frailty are not new.  What this study adds however, is that the number of complications also increases and, perhaps most interestingly, that these associations are not limited to high risk procedures.

The authors also assert that (their analysis indicates that) attempts to ‘rescue’ the frailest patients may be futile, but it’s hard for the reader to assess the validity of this analysis for two reasons.  Firstly, despite descriptions of ‘mediation’ analysis, the authors indicate that they may not have adjusted for casemix and confounding and that the association of complications with mortality has not been accounted for.  And secondly, despite indicating that hierarchical analysis was performed, they report that hospital-level variables were not available in the dataset, so organisational differences in rescue rates has not been accounted for either.

More broadly, limitations include retrospective dataset analysis and use of a frailty tool that was developed within and only validated within this dataset.

But, having discussed the limitations, the headline findings are probably generalisable across adult surgical populations, and the systematic assessment of frailty to inform consent and shared decision making should be encouraged!

Summary by Dr Matt Oliver

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