Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days

Abstract

Importance: As the US population ages, the number of operations performed on elderly patients will likely increase. Frailty predicts postoperative mortality and morbidity more than age alone, thus presenting opportunities to identify the highest-risk surgical patients and improve their outcomes.

Objective: To examine the effect of the Frailty Screening Initiative (FSI) on mortality and complications by comparing the surgical outcomes of a cohort of surgical patients treated before and after implementation of the FSI.

Design, setting, and participants: This single-site, facility-wide, prospective cohort quality improvement project studied all 9153 patients from a level 1b Veterans Affairs medical center who presented for major, elective, noncardiac surgery from October 1, 2007, to July 1, 2014.

Interventions: Assessment of preoperative frailty in all patients scheduled for elective surgery began in July 2011. Frailty was assessed with the Risk Analysis Index (RAI), and the records of all frail patients (RAI score, ≥21) were flagged for administrative review by the chief of surgery (or designee) before the scheduled operation. On the basis of this review, clinicians from surgery, anesthesia, critical care, and palliative care were notified of the patient's frailty and associated surgical risks; if indicated, perioperative plans were modified based on team input.

Main outcomes and measures: Postoperative mortality at 30, 180, and 365 days.

Results: From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16).

Conclusions and relevance: Implementation of the FSI was associated with reduced mortality, suggesting the feasibility of widespread screening of patients preoperatively to identify frailty and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Additional investigation is required to establish a causal connection.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hall reported serving as a consultant to the University of Pennsylvania Medical Center on frailty. Dr Johanning reported holding intellectual property on frailty through FutureAssure LLC. No other disclosures were reported.

Figures

Figure.

The sample included all 9153 patients (5275 before FSI implementation and 3878 after FSI implementation). Mantel-Cox log rank tests for differences in the survival distribution are as follows (P < .001 for overall difference before and after FSI implementation). Before FSI implementation, the lowest 2 strata of frailty were different from each other and from all the other strata (all P < .001). There was no difference between the 16 to 20 and 21 to 25 Risk Analysis Index (RAI) strata (P = .31), although the 16 to 20 RAI stratum was different from the highest 3 strata of frailty (all P < .05). The 21 to 25 RAI stratum was not different from the 26 to 30 (P = .16) or the 31 to 35 (P = .24) RAI stratum, but it was different from the 36 to 62 RAI stratum (P = .004). Although the lines of the highest 3 strata diverge, the differences did not reach statistical significance (all P > .05); however, this is likely attributable to the low numbers in these RAI strata. After FSI implementation, the lowest frailty stratum was different from all others (P < .001), but there was no difference between the next RAI strata (eg, 11–15, 16–20, and 21–25; all P > .20), although these 3 were different from the top 3 strata (all P < .03). There was no difference between the top 3 strata (eg, 26–30, 31–35, and 36–62; all P > .50), but they were all different from each of the lowest 3 strata (all P < .05). Hash marks indicate censored data.