Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery | Geriatrics | JAMA Surgery | JAMA Network
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    Original Investigation
    May 16, 2018

    Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery

    Author Affiliations
    • 1Department of Surgery, Henry Ford Health System, Detroit, Michigan
    • 2Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, New York
    • 3Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia
    • 4Surgical Service Line, Atlanta VA Medical Center, Decatur, Georgia
    • 5Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
    • 6Department of Surgery, University of Pittsburgh, Pittsburgh
    • 7Department of Surgery, University of Nebraska Medical Center, Omaha
    • 8Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
    • 9VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
    • 10Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
    JAMA Surg. 2018;153(5):e180214. doi:10.1001/jamasurg.2018.0214
    Key Points

    Question  What is the association of patient frailty with postoperative complications and failure to rescue after low-risk and high-risk inpatient surgery?

    Findings  In this cohort study of the American College of Surgeons National Surgical Quality Improvement Program, there was a dose-response association between increasing patient frailty, the number of postoperative complications, and failure to rescue. These associations were apparent after low-risk and high-risk inpatient surgical procedures.

    Meaning  Patient frailty should be considered an important component of the preoperative assessment because it may help identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and could provide a framework for shared decision making on initiating surgical care.


    Importance  Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures.

    Objective  To assess the association of frailty with FTR in patients undergoing inpatient surgery.

    Design, Setting, and Participants  This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling.

    Main Outcomes and Measures  The number of postoperative complications and inpatient FTR.

    Results  A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5% for those with scores of 10 or less, 23.7% for those with scores of 11 to 20, 31.1% for those with scores of 21 to 30, 42.5% for those with scores of 31 to 40, and 54.4% for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95% CI, 3.9-7.1). Odds ratios were 8.1 (95% CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95% CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95% CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95% CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95% CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95% CI, 8.1-9.9; vs RAI score >40: 18.4; 95% CI, 15.7-21.4).

    Conclusions and Relevance  Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.