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Original Investigation
Association of VA Surgeons
November 18, 2020

Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties

Author Affiliations
  • 1Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
  • 2Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
  • 3Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
  • 4Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 5Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
  • 6Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 7Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 8Department of Surgery, University of Texas Health San Antonio, San Antonio
  • 9South Texas Veterans Health Care System, San Antonio
  • 10Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
  • 11Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
  • 12Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
  • 13Department of Surgery, University of Nebraska Medical Center, Omaha
  • 14Nebraska Western Iowa Veterans Affairs Health System, Omaha
  • 15Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
JAMA Surg. 2021;156(1):e205152. doi:10.1001/jamasurg.2020.5152
Key Points

Question  Is the association between frailty and postoperative mortality consistent across noncardiac surgical specialties?

Findings  In this cohort study of over 2.7 million unique patients from 2 large, national data sets, frailty was associated with postoperative mortality across all noncardiac surgical specialties independent of operative stress. Frail patients in all surgical specialties had high mortality rates following low- and moderate-stress procedures.

Meaning  This study suggests that preoperative frailty assessment should be implemented across all specialties, regardless of case-mix, to facilitate risk stratification and shared decision-making.


Importance  Frailty is an important risk factor for postoperative mortality. Whether the association between frailty and mortality is consistent across all surgical specialties, especially those predominantly performing lower stress procedures, remains unknown.

Objective  To examine the association between frailty and postoperative mortality across surgical specialties.

Design, Setting, and Participants  A cohort study was conducted across 9 noncardiac specialties in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) from January 1, 2010, through December 31, 2014, using multivariable logistic regression to evaluate the association between frailty and postoperative mortality. Data analysis was conducted from September 15, 2019, to April 30, 2020. Patients 18 years or older undergoing noncardiac procedures were included.

Exposures  Risk Analysis Index measuring preoperative frailty categorized patients as robust (Risk Analysis Index ≤20), normal (21-29), frail (30-39), or very frail (≥40). Operative Stress Score (OSS) categorized procedures as low (1-2), moderate (3), and high (4-5) stress. Specialties were categorized by case-mix as predominantly low intensity (>75% OSS 1-2), moderate intensity (50%-75%), or high intensity (<50%).

Main Outcomes and Measures  Thirty-day (both measures) and 180-day (VASQIP only) postoperative mortality.

Results  Of the patients evaluated in NSQIP (n = 2 339 031), 1 309 795 were women (56.0%) and mean (SD) age was 56.49 (16.4) years. Of the patients evaluated in VASQIP (n = 426 578), 395 761 (92.78%) were men and mean (SD) age was 61.1 (12.9) years. Overall, 30-day mortality was 1.2% in NSQIP and 1.0% in VASQIP, and 180-day mortality in VASQIP was 3.4%. Frailty and OSS distributions differed substantially across the 9 specialties. Patterns of 30-day mortality for frail and very frail patients were similar in NSQIP and VASQIP for low-, moderate-, and high-intensity specialties. Frailty was a consistent, independent risk factor for 30- and 180-day mortality across all specialties. For example, in NSQIP, for plastic surgery, a low-intensity specialty, the odds of 30-day mortality in very frail (adjusted odds ratio [aOR], 27.99; 95% CI, 14.67-53.39) and frail (aOR, 5.1; 95% CI, 3.03-8.58) patients were statistically significantly higher than for normal patients. This was also true in neurosurgery, a moderate-intensity specialty, for very frail (aOR, 9.8; 95% CI, 7.68-12.50) and frail (aOR, 4.18; 95% CI, 3.58-4.89) patients and in vascular surgery, a high-intensity specialty, for very frail (aOR, 10.85; 95% CI, 9.83-11.96) and frail (aOR, 3.42; 95% CI, 3.19-3.67) patients.

Conclusions and Relevance  In this study, frailty was associated with postoperative mortality across all noncardiac surgical specialties regardless of case-mix. Preoperative frailty assessment could be implemented across all specialties to facilitate risk stratification and shared decision-making.

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    1 Comment for this article
    Association between patient frailty and postoperative mortality
    Tomoyuki Kawada, MD | Nippon Medical School
    George et al. examined the association between frailty and thirty-day/180-day postoperative mortality (1). Frailty was an independent risk factor for 30- and 180-day mortality across all noncardiac surgical specialties, and I have some comments about their study.

    First, McIsaac et al. reported the effect of frailty on 1-year postoperative mortality (2). There was a significant association between frailty and 1-year mortality, and the effect size decreased by aging. This means that postoperative mortality in the elderly might be related to frailty and other age-related factors.

    Second, Shinall et al. assessed the association between frailty and thirty-day/90-day/180-day postoperative mortality
    at varying levels of operative stress (3). Among patients who were very frail, mortality rates increased even after the lowest-stress surgical procedures, and mortality continued to increase at 90 and 180 days. They recommended frailty screening, because low- and moderate-stress procedures might be risk among patients who are frail.

    Relating to the second query, Hall et al. reported that implementation of the "Frailty Screening Initiative" was significantly associated with reduced mortality (4). Further cohort/intervention studies are needed to verify the benefit of frailty screening and supporting actions to reduce mortality.

    1. George EL, Hall DE, Youk A, et al. Association between patient frailty and postoperative mortality across multiple noncardiac surgical specialties. JAMA Surg 2021;156(1):e205152.
    2. McIsaac DI, Bryson GL, van Walraven C. Association of frailty and 1-year postoperative mortality following major elective noncardiac surgery: A population-based cohort study. JAMA Surg 2016;151(6):538-45.
    3. Shinall MC Jr, Arya S, Youk A, et al. Association of preoperative patient frailty and operative stress with postoperative mortality. JAMA Surg 2019;155(1):e194620.
    4. Hall DE, Arya S, Schmid KK, et al. Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 Days. JAMA Surg 2017;152(3):233-240.