1. 15th November 2017 James Holmes
Journal Club
15th November 2017
James Holmes

2. 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

3. 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)

4. Data
Data collected from American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
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.

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

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

7. 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

8. 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)

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

10. 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

11. 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

12. 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

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

14. 563 low mFI scorers had life threatening systemic disease?

16. Any Complications

19. Serious complications

22. 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))

23. 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

24. Questions?