PREPARE trial: a protocol for a multicentre randomised trial of frailty-focused preoperative exercise to decrease postoperative complication rates and disability scores

Daniel I McIsaac, Dean A Fergusson, Rachel Khadaroo, Amanda Meliambro, John Muscedere, Chelsia Gillis, Emily Hladkowicz, Monica Taljaard, PREPARE Investigators, Keely Barnes, Sylvain Boet, Laura Boland, Karina Branje, Rodney Breau, Gregory L Bryson, Rosaleen Chun, Irfan Dhalla, Gary Dobson, Elijah Dixon, Antoine Eskander, Alan Forster, Hannah Frazer, Sylvain Gagne, Jayna Holroyd-Leduc, Allen Huang, Joanne Hutton, Eric Jacobsohn, John Joanisse, Ana Johnson, Stephanie Johnson, Manoj M Lalu, Luke T Lavallee, Tien Le, Susan Lee, Cameron Love, Grace Ma, Colin McCartney, Michael McMullen, Husein Moloo, Ronald Moore, Thomas Mutter, Sudhir Nagpal, Julie Nantel, Gregg Nelson, Barbara Power, Tarit Saha, Celena Scheede-Bergdhal, Pablo Serrano, Laura Tamblyn-Watts, Kednapa Thavorn, Daniel Trottier, Carl van Walraven, Brittany Warren, Duminda Wijeysundera, Ilun Yang, Daniel I McIsaac, Dean A Fergusson, Rachel Khadaroo, Amanda Meliambro, John Muscedere, Chelsia Gillis, Emily Hladkowicz, Monica Taljaard, PREPARE Investigators, Keely Barnes, Sylvain Boet, Laura Boland, Karina Branje, Rodney Breau, Gregory L Bryson, Rosaleen Chun, Irfan Dhalla, Gary Dobson, Elijah Dixon, Antoine Eskander, Alan Forster, Hannah Frazer, Sylvain Gagne, Jayna Holroyd-Leduc, Allen Huang, Joanne Hutton, Eric Jacobsohn, John Joanisse, Ana Johnson, Stephanie Johnson, Manoj M Lalu, Luke T Lavallee, Tien Le, Susan Lee, Cameron Love, Grace Ma, Colin McCartney, Michael McMullen, Husein Moloo, Ronald Moore, Thomas Mutter, Sudhir Nagpal, Julie Nantel, Gregg Nelson, Barbara Power, Tarit Saha, Celena Scheede-Bergdhal, Pablo Serrano, Laura Tamblyn-Watts, Kednapa Thavorn, Daniel Trottier, Carl van Walraven, Brittany Warren, Duminda Wijeysundera, Ilun Yang

Abstract

Introduction: Frailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this trial is to evaluate the efficacy of home-based multimodal prehabilitation in decreasing patient-reported disability and postoperative complications in older people with frailty having major surgery.

Methods and analysis: We will conduct a multicentre, randomised controlled trial of home-based prehabilitation versus standard care among consenting patients >60 years with frailty (Clinical Frailty Scale>4) having elective inpatient major non-cardiac, non-neurologic or non-orthopaedic surgery. Patients will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of >3 weeks of prehabilitation (exercise (strength, aerobic and stretching) and nutrition (advice and protein supplementation)). The study has two primary outcomes: in-hospital complications and patient-reported disability 30 days after surgery. Secondary outcomes include survival, lower limb function, quality of life and resource utilisation. A sample size of 750 participants (375 per arm) provides >90% power to detect a minimally important absolute difference of 8 on the 100-point patient-reported disability scale and a 25% relative risk reduction in complications, using a two-sided alpha value of 0.025 to account for the two primary outcomes. Analyses will follow intention to treat principles for all randomised participants. All participants will be followed to either death or up to 1 year.

Ethics and dissemination: Ethical approval has been granted by Clinical Trials Ontario (Project ID: 1785) and our ethics review board (Protocol Approval #20190409-01T). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media.

Trial registration number: NCT04221295.

Keywords: clinical trials; geriatric medicine; surgery.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Study flow. CFS, Clinical Frailty Scale; CNST, Canadian Nutrition Screening Tool; DASI, Duke Activity Status Index; eLOS, expected length of stay; PHQ2-Personal Health Questionnaire; POMS, Postoperative Morbidity Survey; 5TSTS, 5 Times Sit to Stand; TDF, Theoretical Domains Framework; WHODAS, WHO Disability Assessment Schedule.

References

    1. Fowler AJ, Abbott TEF, Prowle J, et al. . Age of patients undergoing surgery. Br J Surg 2019;106:1012–8. 10.1002/bjs.11148
    1. McIsaac DI, Taljaard M, Bryson GL, et al. . Frailty as a predictor of death or new disability after surgery: a prospective cohort study. Ann Surg 2020;271:283–9. 10.1097/SLA.0000000000002967
    1. Rockwood K, Song X, MacKnight C, et al. . A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95. 10.1503/cmaj.050051
    1. Fried LP, Ferrucci L, Darer J, et al. . Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci 2004;59:M255–63. 10.1093/gerona/59.3.M255
    1. McIsaac DI, Wong CA, Huang A, et al. . Derivation and validation of a generalizable preoperative frailty index using population-based health administrative data. Ann Surg 2019;270:102–8. 10.1097/SLA.0000000000002769
    1. McIsaac DI, Bryson GL, van Walraven C. Association of frailty and 1-year postoperative mortality following major elective noncardiac surgery: a population-based cohort study. JAMA Surg 2016;151:538–45. 10.1001/jamasurg.2015.5085
    1. McIsaac DI, Moloo H, Bryson GL, et al. . The association of frailty with outcomes and resource use after emergency general surgery: a population-based cohort study. Anesth Analg 2017;124:1653–61. 10.1213/ANE.0000000000001960
    1. Kim DH, Kim CA, Placide S. Preoperative frailty assessment and outcomes at 6 months or later in older adults undergoing cardiac surgical procedures. Ann Intern Med 2016. 10.7326/M16-0652
    1. Lin H-S, Watts JN, Peel NM, et al. . Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016;16:157. 10.1186/s12877-016-0329-8
    1. Wang J, Zou Y, Zhao J, et al. . The impact of frailty on outcomes of elderly patients after major vascular surgery: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2018;56:591–602. 10.1016/j.ejvs.2018.07.012
    1. Aucoin SD, Hao M, Sohi R, et al. . Accuracy and feasibility of clinically applied frailty instruments before surgery: a systematic review and meta-analysis. Anesthesiology 2020;133:78–95. 10.1097/ALN.0000000000003257
    1. Watt J, Tricco AC, Talbot-Hamon C, et al. . Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis. BMC Med 2018;16:2. 10.1186/s12916-017-0986-2
    1. McIsaac DI, Aucoin SD, Bryson GL, et al. . Complications as a mediator of the perioperative frailty-mortality association. Anesthesiology 2021;134:577–87. 10.1097/ALN.0000000000003699
    1. Alvarez-Nebreda ML, Bentov N, Urman RD, et al. . Recommendations for preoperative management of frailty from the Society for perioperative assessment and quality improvement (SPAQI). J Clin Anesth 2018;47:33–42. 10.1016/j.jclinane.2018.02.011
    1. Guideline for Perioperative Care for People Living with Frailty Undergoing Elective and Emergency Surgery. 1.0 . Centre for perioperative care, 2021. Available:
    1. McIsaac DI, MacDonald DB, Aucoin SD. Frailty for perioperative clinicians. Anesthesia & Analgesia 2020;130:1450–60. 10.1213/ANE.0000000000004602
    1. McIsaac DI, Gill M, Boland L, et al. . Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews. Br J Anaesth 2022;128:244–57. 10.1016/j.bja.2021.11.014
    1. McIsaac DI, Jen T, Mookerji N, et al. . Interventions to improve the outcomes of frail people having surgery: a systematic review. PLoS One 2017;12:e0190071. 10.1371/journal.pone.0190071
    1. Milder DA, Pillinger NL, Kam PCA. The role of prehabilitation in frail surgical patients: a systematic review. Acta Anaesthesiol Scand 2018;62:1356–66. 10.1111/aas.13239
    1. McIsaac DI, Saunders C, Hladkowicz E, et al. . PREHAB study: a protocol for a prospective randomised clinical trial of exercise therapy for people living with frailty having cancer surgery. BMJ Open 2018;8:e022057. 10.1136/bmjopen-2018-022057
    1. McIsaac DI, Hladkowicz E, Bryson GL, et al. . Home-Based prehabilitation with exercise to improve postoperative recovery for older adults with frailty having cancer surgery: the PREHAB randomised clinical trial. Br J Anaesth 2022;173. 10.1016/j.bja.2022.04.006. [Epub ahead of print: 16 May 2022].
    1. Carli F, Bousquet-Dion G, Awasthi R, et al. . Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer. JAMA Surg 2020;155:233. 10.1001/jamasurg.2019.5474
    1. Chan A-W, Tetzlaff JM, Altman DG, et al. . Spirit 2013 statement: defining standard protocol items for clinical trials. Ann Intern Med 2013;158:200. 10.7326/0003-4819-158-3-201302050-00583
    1. Graham ID, Kothari A, McCutcheon C, et al. . Moving knowledge into action for more effective practice, programmes and policy: protocol for a research programme on integrated knowledge translation. Implement Sci 2018;13:22. 10.1186/s13012-017-0700-y
    1. Boney O, Bell M, Bell N, et al. . Identifying research priorities in anaesthesia and perioperative care: final report of the joint National Institute of academic Anaesthesia/James Lind alliance research priority setting partnership. BMJ Open 2015;5:e010006. 10.1136/bmjopen-2015-010006
    1. Canadian frailty network (CFN). top ten frailty priorities , 2017. Published. Available: [Accessed 17 July 2018].
    1. McKeen DM, Banfield JC, McIsaac DI, et al. . Top ten priorities for anesthesia and perioperative research: a report from the Canadian anesthesia research priority setting partnership. Can J Anaesth 2020;67:641–54. 10.1007/s12630-020-01607-6
    1. Bethell J, Puts MTE, Sattar S, et al. . The Canadian frailty priority setting partnership: research priorities for older adults living with frailty. Can Geriatr J 2019;22:23–33. 10.5770/cgj.22.336
    1. Gillis C, Li C, Lee L, et al. . Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology 2014;121:937–47. 10.1097/ALN.0000000000000393
    1. Li C, Carli F, Lee L, et al. . Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 2013;27:1072–82. 10.1007/s00464-012-2560-5
    1. Minnella EM, Awasthi R, Loiselle S-E, et al. . Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery: a randomized clinical trial. JAMA Surg 2018;153:1081–9. 10.1001/jamasurg.2018.1645
    1. Teixeira PJ, Carraça EV, Markland D, et al. . Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Act 2012;9:78. 10.1186/1479-5868-9-78
    1. Michie S, Johnston M. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev 2012;6:1–6. 10.1080/17437199.2012.654964
    1. Hopko DR, Lejuez CW, Ruggiero KJ, et al. . Contemporary behavioral activation treatments for depression: procedures, principles, and progress. Clin Psychol Rev 2003;23:699–717. 10.1016/s0272-7358(03)00070-9
    1. Feng S, Dorrance K, Saunders C. Experience with exercise prehabilitation before cancer surgery for older people with frailty. Can J Anesth Can d’anesthésie 2019;66:131–382. 10.1136/bmjopen-2018-022057
    1. Tudor-Locke C, Craig CL, Aoyagi Y, et al. . How many steps/day are enough? for older adults and special populations. Int J Behav Nutr Phys Act 2011;8:80. 10.1186/1479-5868-8-80
    1. Stovitz SD, VanWormer JJ, Center BA, et al. . Pedometers as a means to increase ambulatory activity for patients seen at a family medicine clinic. J Am Board Fam Pract 2005;18:335–43. 10.3122/jabfm.18.5.335
    1. Laporte M, Keller HH, Payette H, et al. . Validity and reliability of the new Canadian Nutrition Screening Tool in the 'real-world' hospital setting. Eur J Clin Nutr 2015;69:558–64. 10.1038/ejcn.2014.270
    1. Rigby RR, Mitchell LJ, Hamilton K, et al. . The use of behavior change theories in dietetics practice in primary health care: a systematic review of randomized controlled trials. J Acad Nutr Diet 2020;120:1172–97. 10.1016/j.jand.2020.03.019
    1. World Health Organization . Global recommendations on physical activity for health 65 years and above. Available: [Accessed 17 Jul 2018].
    1. Abdellatif S, Hladkowicz E, Lalu MM, et al. . Patient prioritization of routine and patient-reported postoperative outcome measures: a prospective, nested cross-sectional study. Can J Anaesth 2022;69:693–703. 10.1007/s12630-022-02191-7
    1. Marmelo F, Rocha V, Moreira-Gonçalves D, Gonçalves D. The impact of prehabilitation on post-surgical complications in patients undergoing non-urgent cardiovascular surgical intervention: systematic review and meta-analysis. Eur J Prev Cardiol 2018;25:404–17. 10.1177/2047487317752373
    1. Luther A, Gabriel J, Watson RP, et al. . The impact of total body prehabilitation on post-operative outcomes after major abdominal surgery: a systematic review. World J Surg 2018;42:2781–91. 10.1007/s00268-018-4569-y
    1. Santa Mina D, Clarke H, Ritvo P, et al. . Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy 2014;100:196–207. 10.1016/j.physio.2013.08.008
    1. Mainini C, Rebelo PF, Bardelli R, et al. . Perioperative physical exercise interventions for patients undergoing lung cancer surgery: what is the evidence? SAGE Open Med 2016;4:205031211667385. 10.1177/2050312116673855
    1. Ustün TB, Chatterji S, Kostanjsek N, et al. . Developing the world Health organization disability assessment schedule 2.0. Bull World Health Organ 2010;88:815–23. 10.2471/BLT.09.067231
    1. Who disability assessment schedule 2.0 (WHODAS 2.0). World Health organization: WHODAS 2.0, 2014. Available: [Accessed 13 Apr 2014].
    1. Shulman MA, Myles PS, Chan MTV, et al. . Measurement of disability-free survival after surgery. Anesthesiology 2015;122:524–36. 10.1097/ALN.0000000000000586
    1. Wolf AC, Tate RL, Lannin NA, et al. . The world Health organization disability assessment scale, WHODAS II: reliability and validity in the measurement of activity and participation in a spinal cord injury population. J Rehabil Med 2012;44:747–55. 10.2340/16501977-1016
    1. Schlote A, Richter M, Wunderlich MT, et al. . WHODAS II with people after stroke and their relatives. Disabil Rehabil 2009;31:855–64. 10.1080/09638280802355262
    1. Kutlay S, Küçükdeveci AA, Elhan AH, et al. . Validation of the world Health organization disability assessment schedule II (WHODAS-II) in patients with osteoarthritis. Rheumatol Int 2011;31:339–46. 10.1007/s00296-009-1306-8
    1. Garin O, Ayuso-Mateos JL, Almansa J, et al. . Validation of the "World Health Organization Disability Assessment Schedule, WHODAS-2" in patients with chronic diseases. Health Qual Life Outcomes 2010;8:51. 10.1186/1477-7525-8-51
    1. Küçükdeveci AA, Kutlay Şehim, Yıldızlar D, et al. . The reliability and validity of the world Health organization disability assessment schedule (WHODAS-II) in stroke. Disabil Rehabil 2013;35:214–20. 10.3109/09638288.2012.690817
    1. Soberg HL, Finset A, Roise O, et al. . The trajectory of physical and mental health from injury to 5 years after multiple trauma: a prospective, longitudinal cohort study. Arch Phys Med Rehabil 2012;93:765–74. 10.1016/j.apmr.2011.08.050
    1. Shaw J, Beasley E, Hladkowicz E. A survey of older people after major surgery: prioritization of routine and patient-reported postoperative outcome measures. In: Ottawa Quaity & Patient Safety Conference, 2018.
    1. Shulman MA, Kasza J, Myles PS. Defining the minimal clinically important difference and Patient-acceptable symptom state score for disability assessment in surgical patients. Anesthesiology 2020;132:1362–70. 10.1097/ALN.0000000000003240
    1. Grocott MPW, Browne JP, Van der Meulen J, et al. . The postoperative morbidity survey was validated and used to describe morbidity after major surgery. J Clin Epidemiol 2007;60:919–28. 10.1016/j.jclinepi.2006.12.003
    1. Bennett-Guerrero E, Welsby I, Dunn TJ, et al. . The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg 1999;89:514–9. 10.1213/00000539-199908000-00050
    1. Wijeysundera DN, Pearse RM, Shulman MA, et al. . Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018;391:2631–40. 10.1016/S0140-6736(18)31131-0
    1. Moonesinghe SR, Harris S, Mythen MG, et al. . Survival after postoperative morbidity: a longitudinal observational cohort study. Br J Anaesth 2014;113:977–84. 10.1093/bja/aeu224
    1. Gilhooly DA, Cole M, Moonesinghe SR. The evaluation of risk prediction models in predicting outcomes after bariatric surgery: a prospective observational cohort pilot study. Perioper Med 2018;7:6. 10.1186/s13741-018-0088-5
    1. McIsaac DI, Taljaard M, Bryson GL, et al. . Comparative assessment of two frailty instruments for risk-stratification in elderly surgical patients: study protocol for a prospective cohort study. BMC Anesthesiol 2016;16:111. 10.1186/s12871-016-0276-0
    1. Woodfield J, Zacharias M, Wilson G, et al. . Protocol, and practical challenges, for a randomised controlled trial comparing the impact of high intensity interval training against standard care before major abdominal surgery: study protocol for a randomised controlled trial. Trials 2018;19:331. 10.1186/s13063-018-2701-9
    1. Martos-Benítez FD, Gutiérrez-Noyola A, Echevarría-Víctores A. Postoperative complications and clinical outcomes among patients undergoing thoracic and gastrointestinal cancer surgery: a prospective cohort study. Rev Bras Ter Intensiva 2016;28:40–8. 10.5935/0103-507X.20160012
    1. Patel ABU, Reyes A, Ackland GL. Non-Inferiority of retrospective data collection for assessing perioperative morbidity. PeerJ 2015;3:e1466. 10.7717/peerj.1466
    1. Goodman BA, Batterham AM, Kothmann E, et al. . Validity of the postoperative morbidity survey after abdominal aortic aneurysm repair-a prospective observational study. Perioper Med 2015;4:10. 10.1186/s13741-015-0020-1
    1. Richards T, Clevenger B, Keidan J, et al. . PREVENTT: preoperative intravenous iron to treat anaemia in major surgery: study protocol for a randomised controlled trial. Trials 2015;16:254. 10.1186/s13063-015-0774-2
    1. Kasivisvanathan R, Abbassi-Ghadi N, McLeod ADM, et al. . Cardiopulmonary exercise testing for predicting postoperative morbidity in patients undergoing hepatic resection surgery. HPB 2015;17:637–43. 10.1111/hpb.12420
    1. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. 10.1097/
    1. Takahashi T, Kumamaru M, Jenkins S, et al. . In-Patient step count predicts re-hospitalization after cardiac surgery. J Cardiol 2015;66:286–91. 10.1016/j.jjcc.2015.01.006
    1. Fisher SR, Graham JE, Ottenbacher KJ, et al. . Inpatient walking activity to predict readmission in older adults. Arch Phys Med Rehabil 2016;97:S226–31. 10.1016/j.apmr.2015.09.029
    1. Low CA, Bovbjerg DH, Ahrendt S, et al. . Fitbit step counts during inpatient recovery from cancer surgery as a predictor of readmission. Ann Behav Med 2018;52:88–92. 10.1093/abm/kax022
    1. Zhang F, Ferrucci L, Culham E, et al. . Performance on five times sit-to-stand task as a predictor of subsequent falls and disability in older persons. J Aging Health 2013;25:478–92. 10.1177/0898264313475813
    1. Katz S, Ford AB, Moskowitz RW, et al. . Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185:914–9 10.1001/jama.1963.03060120024016
    1. Bansback N, Tsuchiya A, Brazier J, et al. . Canadian valuation of EQ-5D health states: preliminary value set and considerations for future valuation studies. PLoS One 2012;7:e31115. 10.1371/journal.pone.0031115
    1. EuroQoL Group . About EQ-5D. Available: [Accessed 13 OCT 2016].
    1. Canadian Institute for Health Information (CIHI) . Patient reported outcome measures. Available: [Accessed 7 JUN 2018].
    1. Wodchis W, Bushmeneva K, Nikitovic M. Guidelines on person-level costing using administrative databases in Ontario 2013.
    1. Juurlink DN, Croxford R, Chong A, Austin P, Tu J, Laupacis A. Canadian Institute for Health Information Discharge Abstract Database : A Validation Study ICES Investigative Report June 2006 Canadian Institute for Health Information Discharge Abstract Database ; 2006.
    1. Atkins L, Francis J, Islam R, et al. . A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implementation Sci 2017;12:1–18. 10.1186/s13012-017-0605-9
    1. Huijg JM, Gebhardt WA, Crone MR, et al. . Discriminant content validity of a theoretical domains framework questionnaire for use in implementation research. Implementation Sci 2014;9:1–16. 10.1186/1748-5908-9-11
    1. Haddad T, Mulpuru S, Salter I, et al. . Development and evaluation of an evidence-based, theory-grounded online clinical frailty scale tutorial. Age Ageing 2022;51. 10.1093/ageing/afab258. [Epub ahead of print: 02 02 2022].
    1. Fergusson D, Aaron SD, Guyatt G, et al. . Post-Randomisation exclusions: the intention to treat principle and excluding patients from analysis. BMJ 2002;325:652–4. 10.1136/bmj.325.7365.652
    1. Kahan BC, Jairath V, Doré CJ, et al. . The risks and rewards of covariate adjustment in randomized trials: an assessment of 12 outcomes from 8 studies. Trials 2014;15:139. 10.1186/1745-6215-15-139
    1. Hernández AV, Steyerberg EW, Habbema JDF. Covariate adjustment in randomized controlled trials with dichotomous outcomes increases statistical power and reduces sample size requirements. J Clin Epidemiol 2004;57:454–60. 10.1016/j.jclinepi.2003.09.014
    1. Thompson DD, Lingsma HF, Whiteley WN, et al. . Covariate adjustment had similar benefits in small and large randomized controlled trials. J Clin Epidemiol 2015;68:1068–75. 10.1016/j.jclinepi.2014.11.001
    1. Vickers AJ, Altman DG. Statistics notes: analysing controlled trials with baseline and follow up measurements. BMJ 2001;323:1123–4. 10.1136/bmj.323.7321.1123
    1. Austin PC, Ghali WA, Tu JV. A comparison of several regression models for analysing cost of CABG surgery. Stat Med 2003;22:2799–815. 10.1002/sim.1442
    1. Bilimoria KY, Liu Y, Paruch JL, et al. . Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg 2013;217:833–42. 10.1016/j.jamcollsurg.2013.07.385
    1. McIsaac DI, Beaulé PE, Bryson GL, et al. . The impact of frailty on outcomes and healthcare resource usage after total joint arthroplasty: a population-based cohort study. Bone Joint J 2016;98-B:799–805. 10.1302/0301-620X.98B6.37124
    1. McIsaac DI, Wong CA, Huang A. Derivation and validation of a generalizable preoperative frailty index using population-based health administrative data. Ann Surg. 2018;epub. 10.1097/SLA.0000000000002769
    1. Fried TR, Bradley EH, Towle VR, et al. . Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002;346:1061–6. 10.1056/NEJMsa012528
    1. Picorelli AMA, Pereira LSM, Pereira DS, et al. . Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. J Physiother 2014;60:151–6. 10.1016/j.jphys.2014.06.012

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe