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Original Investigation
November 30, 2016

Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days

Author Affiliations
  • 1Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
  • 2Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Surgical Service Line, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
  • 4Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia
  • 5Department of Biostatistics, University of Nebraska Medical Center, Omaha
  • 6Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha
  • 7Department of Surgery, University of Nebraska Medical Center, Omaha
  • 8Department of Surgery, VA Nebraska–Western Iowa Health Care System, Omaha
  • 9Department of Extended Care and Rehabilitation, VA Nebraska–Western Iowa Health Care System, Omaha
  • 10Department of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City
  • 11Office of Health Operations and Management, Department of Veterans Affairs, Veterans Health Administration, Washington, DC
  • 12Department of Surgery, George Washington University School of Medicine, Washington, DC
JAMA Surg. Published online November 30, 2016. doi:10.1001/jamasurg.2016.4219
Key Points

Question  Can surgical outcomes of frail patients be improved by facility-wide frailty screening and subsequent administrative review of perioperative surgical decision making?

Findings  After implementing a quality improvement project called the Frailty Screening Initiative in a prospective cohort of 9153 patients who underwent surgery, postoperative mortality decreased significantly at 30, 180, and 365 days. Multivariate models revealed a 3-fold survival benefit after controlling for age, frailty, and predicted mortality.

Meaning  Frailty screening of preoperative patients is feasible and may be an effective tool for improving surgical outcomes for an aging and increasingly frail US population.

Abstract

Importance  As the US population ages, the number of operations performed on elderly patients will likely increase. Frailty predicts postoperative mortality and morbidity more than age alone, thus presenting opportunities to identify the highest-risk surgical patients and improve their outcomes.

Objective  To examine the effect of the Frailty Screening Initiative (FSI) on mortality and complications by comparing the surgical outcomes of a cohort of surgical patients treated before and after implementation of the FSI.

Design, Setting, and Participants  This single-site, facility-wide, prospective cohort quality improvement project studied all 9153 patients from a level 1b Veterans Affairs medical center who presented for major, elective, noncardiac surgery from October 1, 2007, to July 1, 2014.

Interventions  Assessment of preoperative frailty in all patients scheduled for elective surgery began in July 2011. Frailty was assessed with the Risk Analysis Index (RAI), and the records of all frail patients (RAI score, ≥21) were flagged for administrative review by the chief of surgery (or designee) before the scheduled operation. On the basis of this review, clinicians from surgery, anesthesia, critical care, and palliative care were notified of the patient’s frailty and associated surgical risks; if indicated, perioperative plans were modified based on team input.

Main Outcomes and Measures  Postoperative mortality at 30, 180, and 365 days.

Results  From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16).

Conclusions and Relevance  Implementation of the FSI was associated with reduced mortality, suggesting the feasibility of widespread screening of patients preoperatively to identify frailty and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Additional investigation is required to establish a causal connection.

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