M. Chimukangara1, M. J. Frelich1, M. Bosler1, L. E. Reinb2, A. Szabo2, J. C. Gould1 1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Biostatistics,Milwaukee, WI, USA
Introduction: Frailty is a standardized measure of physiologic reserve that has been used to predict morbidity and mortality following surgical procedures in the elderly. As a state of increased vulnerability to adverse outcomes, frailty is commonly associated with decreased reserves in multiple organ systems, such as declining cognition, physical ability, and health. We hypothesized that frailty, as assessed based on data derived from a large clinical database, would be associated with morbidity and mortality following paraesophageal hernia repair (PEH).
Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for ICD-9 and CPT codes associated with PEH repair. The NSQIP participant use files for the years 2011-2013 were utilized. Only subjects ≥ 60 years old were included. A previously described modified frailty index (mFI), based on 11 clinical variables available in the NSQIP dataset and derived from the model of cumulative deficits, was used to quantify frailty. Outcomes were 30-day mortality and the occurrence of post-operative 30-day complications. The Clavien-Dindo Classification system was used to characterize complication severity. Secondary outcomes were discharge destination and readmission. Multivariate logistic regression was used to determine the relationship between frailty, complications, and mortality.
Results: Of the 4434 PEH repairs performed in patients ≥ 60 years old in the study interval, 885 records were included in the final analysis (20%). Excluded patients were missing 1 or more variables in the 11-point mFI. The overall rate of complications that were Clavien-Dindo Grade ≥ 3 (Grade 3 = requiring endoscopic, radiographic, or surgical intervention) were 6.1%. Mortality was 0.9% (30-day). The overall readmission rate was 8.2% (30-day) and 10.9% of patients were discharged to a facility other than home. Relative to mFI scores of 0, 1, 2, and ≥3, the respective percentages for the four outcomes were as follows; Clavien-Dindo Grade ≥3 complication: 3.2%, 4.7%, 9.8%, and 23.3% (p <0.0001); mortality: 0.0%, 0.9%, 1.8%, and 2.3% (p 0.0974); discharge to facility other than home: 4.4%, 10.9%, 15.7%, and 31.7% (p <0.0001); and readmission: 8.9%, 6.8%, 8.5%, and 16.3% (p 0.1703). Grade ≥3 complications and discharge to a facility other than home were significantly correlated with mFI.
Conclusion: Frailty, as assessed by the mFI, is correlated with postoperative complications and discharge to a facility other than home following paraesophageal hernia repair. Due to many missing variables needed to calculate an 11-item mFI in the NSQIP dataset, significant portions of otherwise eligible patients were excluded from this analysis. The mFI may not be the ideal measure to assess frailty using the NSQIP dataset for this reason. Future investigation is needed to better quantify frailty based on the clinical variables contained in the NSQIP dataset.