Preoperative Frailty Risk in Cranioplasty Patients: Risk Analysis Index Predicts Adverse Outcomes

Abstract

Background: Cranioplasty is a common surgical procedure used to repair cranial defects, and it is associated with significant morbidity and mortality. Although frailty is a strong predictor of poor postoperative outcomes across surgical specialties, little is known about frailty's impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing the effect of the Risk Analysis Index-Administrative (RAI-A) and the Modified Frailty Index-5 (mFI-5) on cranioplasty outcomes. Methods: The National Surgical Quality Improvement Program was queried for patients undergoing cranioplasty between 2012 and 2020. Receiver operating characteristics and multivariable analyses were used to assess the relationship of postoperative outcomes and the RAI-A, mFI-5, and increasing patient age. Results: There were 2864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were women (57.0%) and White (68.5%). The RAI-A had a more robust predictive ability for 30-day mortality (C-Statistic, 0.741; 95% confidence interval (CI), 0.678-0.804) compared with mFI-5 (C-Statistic, 0.574; 95% CI, 0.489-0.659) and increasing patient age (C-Statistic, 0.671; 95% CI, 0.610-0.732). On multivariable analyses, frailty was independently associated with mortality and other poor postoperative outcomes (P < 0.05). Conclusions:The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting mortality. Additionally, the RAI-A showed independent associations with nonhome discharge and postoperative complications (CDII, CDIIIb, and CDIV). The high rates of operative morbidity (5.0%-36.5%) and mortality (0.4%-3.2%) after cranioplasty highlight the importance of identifying independent risk factors for poor cranioplasty outcomes.

Identifying Independent Predictors of Short-Term Postoperative Morbidity in Patients Undergoing Cranioplasty

“…Interestingly, other studies have noted that frailty indices can be used to predict complications. One recent study by Moya et al 16 found that severe frailty was an independent predictor of non-home discharge and postoperative complications as graded by the Clavien-Dindo classification schema. Notably, increased age, longer intraoperative time, implant size greater than 5 cm, and increased ASA class were associated with non-home discharge in our analysis.…”

The risk analysis index demonstrates exceptional discrimination in predicting frailty's impact on neurosurgical length of stay quality metrics

“…The RAI is a concise, 14-item questionnaire that assesses frailty in five key domains that is based on a range of possible scores from 0 to 81, with 0 being the lowest risk, and 81 being the highest risk. 20,23 There are four overall groups of risk levels, from "robust" (a score of 0-20) to "normal" (a score of [21][22][23][24][25][26][27][28][29][30] to "frail" (a score of [31][32][33][34][35][36][37][38][39][40] to "very frail" (Table 1). The mFI-5 is useful for determining health and functional aspects of frailty based on 5 key variables.…”

“…26,34 These consistent results across multiple studies reinforce the RAI's superior discrimination, and its potential adoption in various surgical subspecialties. 23,35 Previous studies have consistently emphasized the impact that major complications can have, potentially leading to increased LOS and lowering the overall quality of care received. 36,37 Frail older adults were more likely to experience postoperative occurrences during their hospital stay, and these occurrences frequently resulted in increased LOS.…”

The risk analysis index demonstrates superior discriminative ability in predicting extended length of stay in pituitary adenoma resection patients when compared to the 5-point modified frailty index

“…Numerous reports have shown the RAI outperforms the mfI-5 in outcome prediction, including in primarily elective surgical procedures, 15 , 16 , 17 PA patients are largely evaluated in the outpatient elective setting, where preoperative risk stratification can formally be assessed. Therefore, accurate preoperative risk stratification tools are needed to provide better surgical decision making in this patient population.…”