Preoperative frailty assessment predicts loss of independence after vascular surgery

Abstract

Objective: Frailty, a clinical syndrome associated with loss of metabolic reserves, is prevalent among patients who present to vascular surgery clinics for evaluation. The Clinical Frailty Scale (CFS) is a rapid assessment method shown to be highly specific for identifying frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to predict loss of independence after major vascular procedures. Methods: We identified all patients living independently at home who were prospectively assessed using the CFS before undergoing an elective major vascular surgery procedure (admitted for >24 hours) at an academic medical center between December 2015 and December 2017. Patient-and procedure-level clinical data were obtained from our institutional Vascular Quality Initiative registry database. The composite outcome of discharge to a nonhome location or 30-day mortality was evaluated using bivariate and multivariate regression models. Results: A total of 134 independent patients were assessed using the CFS before they underwent elective open abdominal aortic aneurysm repair (8%), endovascular aneurysm repair (26%), thoracic endovascular aortic repair (6%), suprainguinal bypass (6%), infrainguinal bypass (16%), carotid endarterectomy (19%), or peripheral vascular intervention (20%). Among 39 (29%) individuals categorized as being frail using the CFS, there was no significant difference in age or American Society of Anesthesiologists physical status compared with nonfrail patients. However, frail patients were significantly more likely to need mobility assistance after surgery (62% frail vs 22% nonfrail; P < .01) and to be discharged to a nonhome location (22% frail vs 6% nonfrail; P ¼ .01) or to die within 30 days after surgery (8% frail vs 0% nonfrail; P < .01). Preoperative frailty was associated with a >12-fold higher risk (odds ratio, 12.1; 95% confidence interval, 2.17-66.96; P < .01) of 30-day mortality or loss of independence, independent of the vascular procedure undertaken. Conclusions: The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care.

Effect of Frailty on Outcome after Traumatic Spinal Cord Injury

“…2 Its association with poor outcomes has been demonstrated in multiple settings, from the community dwelling population to the surgical population. [3][4][5][6][7][8][9][10] This relationship appears particularly relevant in patients requiring emergent procedures. 11,12 In a recent systematic review of the spine surgery literature, frailty has been demonstrated to affect post-operative outcomes such as adverse events (AEs), mortality, and length of stay (LOS).…”

<p>Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence</p>

“…Frailty was also made responsible for longer in-hospital stays and an increased rate of non-home discharge. The need for a higher level of care or nursing facility after hospitalization occurred with a higher incidence compared to non-frail patients 44,45…”

Preoperative Evaluation of the Frail Patient

“…Frail and nonfrail patients had similar surgical procedures in these studies, with exception of vascular procedures, in which frail patients primarily underwent peripheral vascular interventions and were less likely to have major elective vascular surgery than nonfrail patients. 47 A study examining general, vascular, cardiac, thoracic, and orthopedic surgeries in a large population showed that the most robust patients (Risk Analysis Index [RAI] ≤ 10) comprised 80% of the surgical population, while frail patients (RAI ≥ 21) comprised only 7% of the population. 11 As frail patients constitute approximately 15% of community-based individuals who are over 65 years of age, 62 there may be a selection bias where poor operative candidates are excluded from undergoing surgery.…”

“…55 Other studies showed that frailty was predictive of higher risk for 30-day mortality and discharge to a skilled facility, while age and ASA score were not associated with these outcomes. 36,47 However, 1 study found that addition of frailty measurement to ASA class improved the ability to predict postoperative complications and discharge to a skilled nursing facility. 39…”