15th November 2017 James Holmes Journal Club 15th November 2017 James Holmes

Frail ‘weak and delicate, or easily broken’ dictionary ‘Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their reserve.’ BGS

The Article Association of patient frailty with increased morbidity after common ambulatory general surgery operations Journal of the American Medical Association (Surgery) Published online 11/10/17 Retrospective cohort study of 140,828 patients over the age of 40 from 2007 to 2010 who underwent ambulatory and 23 hour stay hernia, breast, thyroid or parathyroid surgery (not requiring sternotomy)

Data Data collected from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2007-2010 NSQIP gets data from around 400 centres and contains prospective, multi-institutional information on patient characteristics and 30 day mortality outcomes for a systematic sample of major inpatient and outpatient surgical procedures at participating institutions.

Cases identified using variables for outpatient procedures and total length of stay. Emergency cases or those with no anaesthesia were excluded

NSQIP modified frailty index (mFI) Adapted from Canadian study of health and aging frailty index Validated to correlate with frailty in all surgical specialities

mFI History of DM Impaired functional status COPD/pneumonia Heart failure MI within 6 months History of PCI Impaired sensorium History of TIA/CVA Cardiac surgery or angina On treatment for hypertension PVD or rest pain 1 point for each variable

mFI 1 point for each variable to give score which is then divided by 11 (total) to give scale of 0 to 1 Low <0.18 (0-1 traits) Intermediate 0.18 – 0.35 (2-3 traits) High >0.35 (>3 traits)

Additional Covariates Age Sex Race/Ethnicity Type of anaesthesia Tobacco use Renal failure Corticosteroid use

Outcomes Primary Any type of 30 day complication As below plus wound site infection and UTI Serious 30 day complication Pneumonia, unplanned intubation, ventilator dependence, cardiac arrest, MI, CVA, coma for >24 hours, AKI, bleeding, sepsis, wound dehiscence, VTE

140,828 patients identified Hernia (71455), breast (51267), thyroid or PT (18106) Low mFI (118,831) Intermediate mFI (21,036) High mFI (961) 139,732 independent 102,539 ASA 1 or 2

Complications 2457 (1.7%) had any type of post op complication 971 (0.7%) had a serious post op complication 1.5% complication in low mFI score 5.8% complication in high mFI score (sig diff, p<0.001

Length of Stay >1 day Low mFI 1.9% Intermediate mFI 3.2% High mFI 5.4% (sig diff p<0.001

563 low mFI scorers had life threatening systemic disease?

Any Complications

Serious complications

Limitations Only 30 day follow up, is this long enough? No data on readmissions Retrospective application of mFI, frailty not assessed at the time Frailty criteria appear to be co-morbidities, incomplete picture of frailty (no formal assessment of functional status (just independent or partially/totally dependent), cognition or mobility))

Limitiations No measure of post op depression, anxiety, loss of independence or accelerated cognitive decline which contribute to frailty Data is mostly from large academic teaching institutions which may not make it applicable to smaller community hospitals NSQIP stopped data collection on some mFI values after 2010 so more recent data could not be used

Questions?