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Original Investigation
Pacific Coast Surgical Association
November 25, 2020

Association of Frailty With Morbidity and Mortality in Emergency General Surgery by Procedural Risk Level

Author Affiliations
  • 1Division of Trauma, Burn, and Surgical Critical Care, Surgery Department, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Surg. 2021;156(1):68-74. doi:10.1001/jamasurg.2020.5397
Key Points

Question  Is level of procedural risk associated with frailty and mortality in emergency general surgery patients?

Findings  In this cross-sectional study of 882 929 emergency general surgery admissions, frailty was significantly associated with mortality. After stratified analysis, this association remained significant for high-risk procedures, and it was even greater within low-risk procedures.

Meaning  Procedural risk level is associated with frailty and mortality in emergency general surgery patients, and preoperative frailty assessment should be strongly considered even within low-risk procedures.

Abstract

Importance  In this aging society, older patients are more commonly undergoing emergency general surgery (EGS). Although frailty has been associated with worse outcomes in this population, EGS encompasses a heterogeneous mix of procedures.

Objective  To determine if the association of frailty with morbidity and mortality in EGS patients varies based on the level of procedural risk.

Design, Setting, and Participants  This cross-sectional study analyzed Medicare inpatient claims file (January 2007-December 2015) and included all inpatients who underwent 1 of 7 previously described EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Analysis took place from September 2019 to January 2020.

Exposures  The primary exposure of interest was risk procedural level. EGS procedures were stratified as high risk (excision of small intestine, excision of large intestine, peptic ulcer repair, lysis of peritoneal adhesions, and laparotomy) and low risk (appendectomy and cholecystectomy).

Main Outcomes and Measures  The primary outcome was overall 30-day mortality after discharge. Frailty was assessed using a claims-based frailty index. Multivariate logistic regression analysis was used and was stratified by risk level.

Results  A total of 882 929 EGS patients were included in this study (mean [SD] age, 77.9 [7.5] years; 483 637 [54%] were female). Overall mortality was 4.5% (n = 40 304). The frailty index classified 12.6% (n = 111 513) of patients as frail, and mortality within this group was 9.9% (n = 11 307). High-risk procedures represented 53% (n = 468 098) of the caseload, and mortality was 6.8% (n = 31 979). For low-risk procedures, mortality was 2% (n = 8325). Frailty was significantly associated with mortality (odds ratio, 1.64; 95% CI, 1.60-1.68). After stratified analysis, this association remained significant for high-risk (odds ratio, 1.53; 95% CI, 1.49-1.58) and low-risk (odds ratio, 2.05; 95% CI, 1.94-2.17) procedures.

Conclusions and Relevance  Frailty was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures.

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    1 Comment for this article
    EXPAND ALL
    IF Emergency Abdominal Surgery, the Frail Patients Are Deserved to Pay More Attention
    Fei Zhang, MD, MPH | Department of Hepatobiliary and Pancreatic Surgery, Hunnan Division of The First Affiliated Hospital of China Medical University
    Castillo-Angeles and colleagues [1] found that frailty was significantly associated with mortality in patients undergoing emergency general surgery (EGS), with an even more significant association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures. However, in our opinion, the association of frail with mortality was overestimated, and several problems and shortcomings in the study may make the conclusion misleading and biased.

    First, due to this cross-sectional study, the level of evidence seems not high. The authors [1] ignored the preoperative anesthesia evaluation for older patients during urgent or emergent admission. The patients have been screened and
    evaluated by anesthesiologists before EGS. In this study [1], the not frail group was significantly higher than the frail group (771416 vs. 111513). Consequently, this may lead to selection bias.

    Second, although the authors [1] used the claims-based frailty index (CFI) to define frailty, there is no accepted “gold standard” measurement of frailty in aging patients [2]. We recommend using more frailty tools to balance the bias, such as the clinical frailty scale (CFS), the FRAIL scale, the Fried frailty phenotype, the Edmonton frail scale, and the comprehensive geriatric assessment-frailty index (CGA-FI) [2]. Furthermore, Simon et al. reported that the five-item modified frailty index (mFI-5) score was also used to assess frailty [3]. Thus, the optimal choice of the assessment tool is still needed to explore.

    Although there may be a few problems at this stage, it has the potential to reduce substantial morbidity and mortality in aging adults and improve surgical care in the long-term globally [4,5]. There are also face with the aging procession in China under the rigorous relationship between surgeons and patients [2]. Some hospitals have already conducted frailty measurements before every procedure, including EGS. Overall, this study [1] suggests that frailty assessments should deserve more attention to the preoperative evaluation regardless of the risk. Large-scale, high-quality multicenter studies are required before the frailty assessment can be warranted in clinical practice.

    Author Information: Fei Zhang, MD, MPH; Chunlin Ge, MD. Department of Hepatobiliary and Pancreatic Surgery, Hunnan Division of The First Affiliated Hospital of China Medical University.
    Corresponding Author: Chunlin Ge, MD, gechunlin@139.com

    REFERENCES
    1. Castillo-Angeles M, Cooper Z, Jarman MP, Sturgeon D, Salim A, Havens JM. Association of Frailty With Morbidity and Mortality in Emergency General Surgery By Procedural Risk Level. JAMA Surg. Published November 25, 2020. doi:10.1001/jamasurg.2020.5397
    2. Liang YD, Zhang YN, Li YM, et al. Identification of Frailty and Its Risk Factors in Elderly Hospitalized Patients from Different Wards: A Cross-Sectional Study in China. Clinical interventions in aging. 2019;14:2249-2259.
    3. Simon HL, Reif de Paula T, Profeta da Luz MM, Nemeth SK, Moug SJ, Keller DS. Frailty in older patients undergoing emergency colorectal surgery: USA National Surgical Quality Improvement Program analysis. The British journal of surgery. 2020;107(10):1363-1371.
    4. Anderson D, Wick EC. Frailty and Postoperative Morbidity and Mortality-Here, There, and Everywhere. JAMA Surg. Published November 18, 2020. doi:10.1001/jamasurg.2020.5153
    5. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet. 2019;394(10206):1365-1375. doi: 10.1016/S0140-6736(19)31786-6
    CONFLICT OF INTEREST: None Reported
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