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Original Investigation
Pacific Coast Surgical Association
February 2018

Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations

Author Affiliations
  • 1Department of Surgery, University of California, San Francisco
JAMA Surg. 2018;153(2):160-168. doi:10.1001/jamasurg.2017.4007
Key Points

Question  Is frailty associated with perioperative morbidity in patients undergoing ambulatory hernia, breast, thyroid, or parathyroid surgery?

Findings  In this cohort study, an increasing National Surgical Quality Improvement Program modified frailty index was associated with a stepwise increase in the incidence of 30-day complications; an intermediate modified frailty index (2-3 frailty traits) and a high modified frailty index (≥4 frailty traits) were significantly associated with any type of complication and with serious complications, respectively, in multivariable analysis adjusting for other risk factors and clustering by operation. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications.

Meaning  Frailty is independently associated with perioperative morbidity in patients undergoing common ambulatory general surgery and should be considered in patient selection and counseling.

Abstract

Importance  Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.

Objective  To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.

Design, Setting, and Participants  A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.

Main Outcomes and Measures  The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.

Results  A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001).

Conclusions and Relevance  Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.

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