E. L. George1,1,2, S. Arya1,1,2, A. Youk3,4, A. Kashikar1,1, R. Chen1,1, A. W. Trickey1,1, M. C. Shinall5, N. N. Massarweh6, J. M. Johanning7, D. E. Hall3,4 1Stanford University,Vascular Surgery,Palo Alto, CA, USA 1Stanford University,Stanford-Surgery Policy Improvement Research & Education Center,Palo Alto, CA, USA 2VA Palo Alto Healthcare Systems,Palo Alto, CA, USA 3University Of Pittsburg,Pittsburgh, PA, USA 4VA Pittsburgh Healthcare System,Pittsburgh, PA, USA 5Vanderbilt University Medical Center,Nashville, TN, USA 6Baylor College Of Medicine,Houston, TX, USA 7Nebraska Medical Center,Omaha, NE, USA
Introduction: Frailty is associated with increased 180-day mortality after surgical procedures; however, it remains unclear whether this relationship is consistent across surgical specialties, particularly for those who predominantly perform low-stress or “minor” procedures. Thus, we sought to describe the relationship between frailty and mortality across surgical specialties stratified by the rendered surgical stress.
Methods: Retrospective cohort study from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) including non-cardiac procedures in 8 VASQIP-defined specialties (2010-14). We calculated the Risk Analysis Index of frailty (RAI) according to published protocols, grouped into 4 categories with increasing frailty severity (≤20 “robust”, 21-29 “average”, 30-39 “frail”, ≥40 “very frail”). Operative Stress Scores (OSS) were assigned (1=lowest stress and 5=highest stress) to 565 common surgical CPT codes by a modified Delphi consensus method. The specialties were then divided into 3 groups by proportion of low-stress cases performed (OSS 1-2). The primary endpoint was 180-day mortality.
Results: A total of 464,697 patients had surgery across 8 surgical specialties. Specialties were categorized as: 1) predominantly low-risk with >75% OSS 1-2 cases [orthopedic (75.6%), otolaryngologic (78.3%), plastic (89.9%), and urologic (75.6%) surgery], 2) moderate-risk with 50-75% OSS 1-2 cases [general (57.2%) and neurologic (53.1%) surgery], and 3) high-risk with <50% OSS 1-2 cases [thoracic (19.9%) and vascular (26.96%) surgery]. Mean RAI varied significantly (p<0.001): low-risk specialties mean RAI 20.72 (SD 7.12), moderate-risk 21.30 (7.59), and high-risk 24.97 (7.02). Overall 180-day mortality was 3.6%. Very frail patients had 22.7% mortality at 180 days following a low-stress procedure (OSS 1-2) for low-risk specialties, similar to moderate- (25.6%) and high-risk (30.2%) specialties. OSS 1-2 operations were not low risk for patients of high-risk specialties as they had the highest average mortality rates within each frailty level [Figure 1, left panel]. Furthermore, when low-risk specialties perform higher operative stress procedures, their 180-day mortality rates for frail and very frail patients are comparable to moderate- and high-risk specialties, where 25-50% of patients are dead at 6 months [Figure 1, middle and right panels].
Conclusion: Frailty is associated with worse 180-day mortality across surgical specialties with mortality upwards of 20% even for low-stress procedures. Thus, we recommend preoperative frailty assessment in all surgical specialties regardless of whether a low- or high-stress procedure is planned.
