Frailty and postoperative survival
Elderly and frail patients make up a growing proportion of surgical patients, and their outcomes are not always good. Could a screening for frailty followed by a review of perioperative surgical decision-making help to improve the situation? The present US-wide study implemented a quality improvement project called the Frailty Screening Initiative (FSI) and investigated its effects in a cohort of 9,153 surgical patients who were treated before and after the implementation. The positive result: Postoperative mortality decreased significantly.
Frailty was assessed using the Risk Analysis Index (RAI), with “frailty” being defined as a RAI score ≥ 21. All records of frail patients underwent administrative review by the chief of surgery before the scheduled operation. On the basis of this review, treating physicians (surgery, anesthesia, critical care, and palliative care) were notified of the patient’s frailty and associated surgical risks, and subsequently, if indicated, modified perioperative plans.
After implementation of the FSI, overall 30-day mortality decreased from 1.6 % to 0.7 % (P < 0.001). Frail patients saw the greatest improvement (12.2 % to 3.8 %, P < 0.001), but more robust patients benefitted as well (1.2 % to 0.3 %, P < 0.001). The magnitude of improvement among frail patients increased at 180 and at 365 days after surgery (23.9 % to 7.7 % and 34.5 % to 11.7 %, respectively; P < 0.001). Survival after FSI implementation increased almost threefold after controlling for age, frailty, and predicted mortality (adjusted OR for 180-day survival: 2.87).
Implementation of the FSI was associated with reduced mortality. The authors suggest widespread preoperative screening in order to identify frail patients and to install initiatives to improve their surgical outcomes.