Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality | Geriatrics | JAMA Surgery | JAMA Network
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    2 Comments for this article
    Differentiation between emergency and elective surgery for operative stress assessment
    Rahul Gupta, MBBS, MS, MCh | Synergy Institute of Medical Sciences
    I read with interest the article by Shinall et al on the association between patient fraility and operative stress. But on reading the details about the operative stress score, I did not understand how the stress associated with emergency surgery was taken in to account. For example, a given patient undergoing emergency open colectomy for intestinal obstruction or perforation is obviously having higher operative stress compared to a patient undergoing elective open colectomy. The authors need to clarify whether this aspect was taken in to consideration while preparing operative risk score.
    Response to Dr. Gupta on behalf of the authors
    Amalia Cochran, MD | The Ohio State University
    We thank the reader for this perceptive comment, and we agree that the emergent vs. elective status of the surgical procedure is of paramount importance. In developing the Operative Stress Score, the raters were asked to consider the stress associated with the procedure in an elective setting. The dataset used for the published analysis included all surgeries included in VASQIP for the specified years, both elective and emergent. Our intention was to provide an analysis that was generalizable to the broadest sample of surgery as actually performed across the VA. However, this reader is not the first to inquire about the relative impact of emergency status on our analysis, and thus we have just completed subgroup analyses that examine the relationship of operative stress, frailty and mortality in elective and emergent contexts. In brief, although mortality is higher among emergent surgeries, the same pattern of mortality and frailty across all ranges of operative stress is observed in both the emergent and elective sub-samples. We have submitted these findings for consideration as a peer-reviewed publication.
    Original Investigation
    November 13, 2019

    Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality

    Author Affiliations
    • 1Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
    • 2Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
    • 3Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
    • 4Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
    • 5Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 6Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 7Department of Surgery, Henry Ford Health System, Detroit, Michigan
    • 8Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
    • 9Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
    • 10Department of Surgery, University of Texas Health San Antonio, San Antonio
    • 11South Texas Veterans Health Care System, San Antonio
    • 12Department of Surgery, University of Nebraska Medical Center, Omaha
    • 13Nebraska Western Iowa Veterans Affairs Health System, Omaha
    • 14Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
    • 15Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 16Department of Surgery, Stanford University, Palo Alto, California
    • 17Deparment of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
    • 18Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha
    • 19Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 20Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
    • 21Division of Urology, University of Nebraska Medical Center, Omaha
    • 22Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
    • 23Perioperative Surgical Home, Henry Ford Health System, Detroit, Michigan
    • 24Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
    • 25Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan
    • 26Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha
    • 27Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
    • 28Department of Neurosurgery, University of Nebraska Medical Center, Omaha
    • 29Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
    JAMA Surg. 2020;155(1):e194620. doi:10.1001/jamasurg.2019.4620
    Key Points

    Question  Is frailty associated with increased risk of postoperative mortality across all levels of operative stress?

    Findings  In this cohort study of 432 828 unique patients, frailty was associated with increased 30-, 90-, and 180-day mortality across all levels of operative stress. Mortality among patients with frailty after low- and moderate-stress procedures was substantially higher than mortality rates usually associated with high-risk surgical procedures.

    Meaning  The findings suggest that even minor surgical procedures are associated with high risk for patients with frailty and that surgeons and referring physicians should consider whether the potential benefits of surgery warrant the increased risk.


    Importance  Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood.

    Objective  To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study.

    Design, Setting, and Participants  This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress.

    Exposures  Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score.

    Main Outcomes and Measures  Postoperative mortality at 30, 90, and 180 days.

    Results  Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures.

    Conclusions and Relevance  We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.