Automated Electronic Frailty Index is Associated with Non-home Discharge in Patients Undergoing Open Revascularization for Peripheral Vascular Disease

Abstract

Background Frailty is associated with adverse surgical outcomes including post-operative complications, needs for post-acute care, and mortality. While multiple frailty screening tools exist, most are time and resource intensive. Here we examine the association of an automated electronic frailty index (eFI), derived from routine data in the Electronic Health Record (EHR), with outcomes in vascular surgery patients undergoing open, lower extremity revascularization. Methods A retrospective analysis at a single academic medical center from 2015 to 2019 was completed. Information extracted from the EHR included demographics, eFI, comorbidity, and procedure type. Frailty status was defined as fit (eFI≤0.10), pre-frail (0.10<eFI≤0.21), and frail (eFI>0.21). Outcomes included length of stay (LOS), 30-day readmission, and non-home discharge. Results We included 295 patients (mean age 65.9 years; 31% female), with the majority classified as pre-frail (57%) or frail (32%). Frail patients exhibited a higher degree of comorbidity and were more likely to be classified as American Society of Anesthesiologist class IV (frail: 46%, pre-frail: 27%, and fit: 18%, P = 0.0012). There were no statistically significant differences in procedure type, LOS, or 30-day readmissions based on eFI. Frail patients were more likely to expire in the hospital or be discharged to an acute care facility (31%) compared to pre-frail (14%) and fit patients (15%, P = 0.002). Adjusting for comorbidity, risk of non-home discharge was higher comparing frail to pre-frail patients (OR 3.01, 95% CI 1.40-6.48). Discussion Frail patients, based on eFI, undergoing elective, open, lower extremity revascularization were twice as likely to not be discharged home.

Automated Electronic Frailty Index–Identified Frailty Status and Associated Postsurgical Adverse Events

“…The availability of tools such as the eFI is increasingly important in the perioperative realm, as higher frailty scores are indicative of increased postoperative care needs, including hospital length of stay and discharge to transitional care facilities, 30-day readmission rates, and all-cause mortality. 1,3,8 However, these tools demonstrate substantial heterogeneity in their association with postoperative surgical complication risk; therefore, a closer examination is necessary. 8 In a previous study, Callahan et al 1 grouped patients into 3 frailty categories using eFI scores (fit, prefrail, and frail) and found that a patient's likelihood for worse outcomes increased as the severity of frailty increased.…”

“…8 In a previous study, Callahan et al 1 grouped patients into 3 frailty categories using eFI scores (fit, prefrail, and frail) and found that a patient's likelihood for worse outcomes increased as the severity of frailty increased. 2,3 The eFI calculation includes comorbidities, which could also play a role in adverse outcomes (eTables 1 and 2 in Supplement 1). Furthermore, while the eFI has been constructed and validated in an accountable care organization in adults older than 65 years, its with critical illness not expected to survive without the operation) or VI (indicating individuals with brain death being considered as organ donors) and patients with insufficient historical data to calculate the eFI (eTable 6 in Supplement 1).…”

“…The deficit accumulation model of frailty posits that a higher prevalence of aging-related health deficits is associated with increased frailty risk. An automated approach that captures such deficits has been developed in the form of the electronic frailty index (eFI), a scalable frailty screening instrument for a range of adverse outcomes in both primary care and surgical settings . At the Wake Forest University School of Medicine and associated hospital systems, an eFI was integrated into the electronic health record (EHR) in October 2019 (eTables 1 and 2 in Supplement 1).…”

“…This eFI score is updated on a weekly basis for all patients 55 years or older. The availability of tools such as the eFI is increasingly important in the perioperative realm, as higher frailty scores are indicative of increased postoperative care needs, including hospital length of stay and discharge to transitional care facilities, 30-day readmission rates, and all-cause mortality . However, these tools demonstrate substantial heterogeneity in their association with postoperative surgical complication risk; therefore, a closer examination is necessary …”

“…In a previous study, Callahan et al grouped patients into 3 frailty categories using eFI scores (fit, prefrail, and frail) and found that a patient’s likelihood for worse outcomes increased as the severity of frailty increased . The eFI calculation includes comorbidities, which could also play a role in adverse outcomes (eTables 1 and 2 in Supplement 1).…”