Frailty Is a Risk Factor for Postoperative Mortality in Patients With Cirrhosis Undergoing Diverse Major Surgeries

Mahmud, Nadim; Kaplan, David E.; Taddei, Tamar H.; Goldberg, David S.

doi:10.1002/lt.25953

Cited by 19 publications

(22 citation statements)

References 38 publications

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“…Furthermore, the overall postoperative mortality in the BIDMC and UPHS cohorts is in general agreement with the established literature, supporting the validity of these data. ( 2,17‐19 ) Second, although we found the VOCAL‐Penn score to be externally valid at BIDMC and UPHS, both of these hospitals represent networks with tertiary expertise and transplant experience. In particular, given increased experience with complex patients with advanced liver disease, academic transplant centers are likely better equipped to address postoperative complications such as hepatic decompensation and infection, which may result in mortality.…”

Section: Discussionmentioning

confidence: 87%

External Validation of the VOCAL‐Penn Cirrhosis Surgical Risk Score in 2 Large, Independent Health Systems

et al. 2021

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Cirrhosis poses an increased risk of postoperative mortality, yet it remains challenging to accurately risk stratify patients in clinical practice. The VOCAL-Penn cirrhosis surgical risk score was recently developed and internally validated in the national Veterans Affairs health system; however, to date this score has not been evaluated in independent cohorts. The goal of this study was to compare the predictive performance of the VOCAL-Penn to the Mayo risk, Model for End-Stage Liver Disease (MELD), and MELD-sodium (MELD-Na) scores in 2 large health systems. We performed a retrospective cohort study of patients with cirrhosis undergoing surgical procedures of interest at the Beth Israel Deaconess Medical Center or University of Pennsylvania Health System from January 1, 2008, to October 1, 2015. The outcomes of interest were 30-day and 90-day postoperative mortality. Concordance statistics (C-statistics), calibration curves, Brier scores, and the index of prediction accuracy (IPA) were compared for each predictive model. A total of 855 surgical procedures were identified. The VOCAL-Penn score had the numerically highest C-statistic for 90-day postoperative mortality (eg, 0.82 versus 0.79 Mayo versus 0.78 MELD-Na versus 0.79 MELD), although differences were not statistically significant. Calibrations were excellent for the VOCAL-Penn, MELD, and MELD-Na; however, the Mayo score consistently overestimated risk. The VOCAL-Penn had the lowest Brier score and highest IPA at both time points, suggesting superior overall predictive model performance. In subgroup analyses of patients with higher MELD scores, the VOCAL-Penn had significantly higher C-statistics compared with the MELD and MELD-Na. The VOCAL-Penn score (www.vocal penns core.com) has excellent discrimination and calibration for postoperative mortality among diverse patients with cirrhosis. Overall performance is superior to the Mayo, MELD, and MELD-Na scores. In contrast to the MELD/MELD-Na, the VOCAL-Penn retains excellent discrimination among patients with higher MELD scores.

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Section: Discussionmentioning

confidence: 87%

External Validation of the VOCAL‐Penn Cirrhosis Surgical Risk Score in 2 Large, Independent Health Systems

et al. 2021

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“…Since the development and validation of the hospital frailty risk score in the acute care setting [ 9 ], the association between HFRS score and adverse events has been replicated in numerous in-patient [ 11 – 14 ] and procedural settings [ 15 – 17 ]. In the peri-operative setting, higher HFRS scores have been associated with adverse events in patients undergoing spinal surgery [ 18 ], joint arthroplasty [ 19 ], vascular surgery [ 20 ] and cirrhotic patients undergoing surgery [ 21 ]. In a generalizable cohort of 487,197 patients over the age of 50 undergoing surgery Harvey et al demonstrated that a high HFRS was associated with prolonged length of stay, 30-day mortality and 28-day readmission [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Beyond the revised cardiac risk index: Validation of the hospital frailty risk score in non-cardiac surgery

et al. 2022

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Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50–1.74) and 1·55 (95% CI 1·38–1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.

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“…The PFI has been validated in patients undergoing noncardiac surgery and is robust in the presence of missing data and variable substitution . In addition, both PFI and HFRS have been previously shown to be associated with 1-year mortality in the noncardiac surgical setting. We assessed the PFI as a continuous variable as well as having it categorized into quintiles.…”

Section: Methodsmentioning

confidence: 99%

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

et al. 2022

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IMPORTANCELittle is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery. OBJECTIVE To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017.Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022. MAIN OUTCOMES AND MEASURESThe primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument. RESULTSOf 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC. CONCLUSIONS AND RELEVANCEThese findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.

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Frailty Is a Risk Factor for Postoperative Mortality in Patients With Cirrhosis Undergoing Diverse Major Surgeries

Cited by 19 publications

References 38 publications

External Validation of the VOCAL‐Penn Cirrhosis Surgical Risk Score in 2 Large, Independent Health Systems

External Validation of the VOCAL‐Penn Cirrhosis Surgical Risk Score in 2 Large, Independent Health Systems

Beyond the revised cardiac risk index: Validation of the hospital frailty risk score in non-cardiac surgery

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

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