Frailty screening predicts risk of poor outcomes after surgery

OTTAWA: A checklist to screen for frailty before surgery could help doctors identify patients who are most likely to have poor outcomes and repeat hospitalizations, researchers say.

The greatest value of this rapid-screening tool may be in helping surgeons identify people whose vulnerability isn’t obvious or due only to age, and to take steps to lessen those risks before surgery, the study team writes in Canadian Medical Association Journal.

After emergency abdominal surgery, for example, frail patients “are at higher risk for poor health outcomes, compared to others their age. It is a person’s frailty, not age, which impacts their chance of readmission or death,” senior study author Dr. Rachel Khadaroo said.

“With this knowledge, we are doing further work to determine if targeted interventions can improve outcomes in this vulnerable population,” said Khadaroo, a surgeon at the University of Alberta in Edmonton, Canada.

“The elderly are the fastest growing population in North America. As a surgeon I want to ensure we are able to provide the best care for all ages, and to do this we need to understand what puts patients at risk,” she added in an email.

To see if a frailty screening tool accurately predicted how patients would fare, Khadaroo’s team examined medical records for 308 patients age 65 or older who had emergency abdominal surgery in 2014 or 2015.

The researchers assessed patients’ frailty status in the two weeks before the admission for surgery by interviewing them or their surrogates, or by deriving the information from medical records.

Using the Canadian Study of Health and Aging Clinical Frailty Scale, they classified 23 percent of patients as being well, 55 percent as vulnerable and 22 percent as mild or moderately frail.

Vulnerable patients were defined as those who had other health conditions and limited activity but who were not disabled.

Mildly frail patients needed help in one or two activities of daily living like food preparation or housework. Moderately frail patients needed help with more-basic tasks like eating or bathing. The most severely frail patients were not included in the analysis.

At 30 days after surgery, compared to patients who were classified as being well before surgery, patients who were vulnerable or frail were more than four and a half times as likely to have been readmitted or to die. At the six-month mark, vulnerable patients still had more than twice the odds of readmission or death, and frail patients were more than three times as likely to have those outcomes. This risk was independent of other clinical and surgical factors, the researchers note.

Physicians should know that not only frail patients are at risk, “but also those who are pre-frail (or at risk of becoming frail) are four times more likely to be readmitted to hospital or to die within 30 days following emergency abdominal surgery,” Khadaroo said.

“The pre-frail population have no apparent disability and for this reason, validated tools to measure the degree of frailty are beneficial to identify this potentially under-recognized high-risk group,” she noted.

Frailty could also be used as a measure of surgery outcome, Olga Theou and Dr. Samuel Searle of Dalhousie University in Halifax, Nova Scotia, write in an accompanying editorial.

“It is a measure of overall health state and, arguably, a better predictor of adverse health outcomes than other individual health measures, although it is a dynamic process,” they write.

Currently, frailty tools are not routinely used in many clinical practices, especially outside geriatrics, Theou told Reuters Health in an email.

“Even so, the evidence consistently shows that frailty is a good predictor of adverse health outcomes, so I am expecting that we will see an increase in their use,” she said.