5-Item Modified Frailty Index Research Articles

The modified 5-item frailty index is a predictor of perioperative risk in head and neck microvascular reconstruction: An analysis of 3795 cases

BackgroundThe modified frailty index 5 (mFI-5)—a scale based on the five variables diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and functional dependency—has been shown to be a valid predictor of surgical outcomes. In this study we sought to evaluate the ability of the mFI-5 to predict the postoperative outcomes of head and neck microvascular reconstruction. MethodsReview of the 2015–2019 American College of Surgeons, National Surgical Quality Improvement Program (ACS NSQIP) database identified 5323 cases of microvascular reconstruction, of which 3795 were head and neck cases that provided parameters necessary to calculate the mFI-5. The groups were compared in terms of demographics and comorbidities. Post-operative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and non-home discharge. ResultsIncreases in the mFI were associated with longer hospitalization periods (10.5 ± 7.5 days in mFI 0 vs 14.9 ± 15.4 in mFI ≥ 3; p < 0.0001) higher rates of mortality (1% in mFI 0 vs 3.1% in mFI ≥ 3; p = 0.02), reoperation (15.4% in mFI 0 vs 17.2% in mFI ≥ 3; p = 0.002) and unplanned readmission (7.6% in mFI 0 vs 18.8% in mFI ≥ 3; p = 0.001). Rates of any complications (p < 0.0001), as well as surgical (p < 0.002) and medical (p < 0.0001) complications specifically were higher with greater mFI scores. Higher mFI scores also predicted decreased home discharge (p < 0.0001). Differences remained significant on multivariate analysis and subgroup analysis by age. ConclusionThe mFI-5 is a significant predictor of risk in microvascular head and neck reconstruction. Subgroup analysis by age highlights that the tool can help identify younger patients who are frail and hence at risk. Through appropriate pre-operative identification of frail patients surgeons can prospectively modify their operative and discharge planning as well as post-operative support.

5-Item Modified Frailty Index as a Preoperative Predictor of Morbidity Following Minimally Invasive Partial Nephrectomy

ObjectiveTo apply the modified frailty index-5 (mFI-5) to those patients undergoing minimally invasive partial nephrectomy (MIPN) to examine the relationship between frailty and postoperative outcomes. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, data were retrospectively reviewed between 2012 and 2018 for cases coded for MIPN. The mFI-5 score was defined on a scale of 1 to 5, with each patient receiving one point per each of the following comorbidities: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension that requires medication and functional health status of partial or total dependence prior to surgery. Complications were examined within the first 30 days postoperatively. Using univariate and multivariate logistic regression, postoperative outcomes were obtained and stratified based on frailty score. ResultsOf the 18,904 cases identified between 2012 and 2018, mFI-5 score was 0 for 38.0% of patients, 1 for 42.8%, ≥2 for 19.2%. With increasing mFI-5 score, a significant increase in multiple postoperative morbidities were identified (P <0.05). 11.2% of patients with mFI-5 ≥2 had complications vs 5.3% with mFI-5 of 0 and 7.8% mFI-5 of 1, P <0.05. Multivariate analysis revealed nearly 50% increase in the odds of having an overall complication for patients with mFI-5 score ≥2 (OR = 1.48, 95% CI 1.22 - 1.80, P <0.001). ConclusionThe mFI-5 is a well defined and easily ascertainable predictor of postoperative outcomes in those undergoing MIPN and could be used preoperatively to identify and counsel those at increased risk for morbidity.

Increasing Frailty in Geriatric Emergency General Surgery: A Cause for Concern

Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5=0, mFI-5=1, mFI-5=2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. A total of 47,216 patients were included: 27.4% with mFI-5=0, 45% with mFI-5=1, 22.1% with mFI-5=2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5=1: odds ratio (OR) 1.48, p=0.003; mFI-5=2: OR 2.66, p <0.001; mFI-5 ≥ 3: OR 3.97, p <0.001), 30-day complications (mFI-5=1: OR 1.46, p <0.001; mFI-5=2: OR 2.48, p <0.001; mFI-5≥3: OR 5.01, p <0.001), reoperation (mFI-5=1: OR 1.42, p = 0.020; mFI-5=2: OR 1.70, p = 0.021; mFI-5 ≥ 3: OR 2.18, p = 0.009) and all-cause mortality (mFI-5=1: OR 1.49, p=0.001; mFI-5=2: OR 2.67, p <0.001; mFI-5 ≥ 3: 3.96, p <0.001). Increasing frailty in geriatric EGS patients is associated with significantly higher rates of FTR, 30-day complications, reoperations, and all-cause mortality. The mFI-5 score can be used to assess frailty and better anticipate the postoperative course of vulnerable geriatric patients.

Evaluating a high-dimensional machine-learning model to predict hospital mortality among elderly cancer patients.

1512 Background: Elderly hospitalized cancer patients face high risks of inpatient hospital mortality. Identifying patients at high risk of hospital mortality could help with risk stratification, and potentially help inform future interventions aimed at improving outcomes. We evaluated the predictive capacity of a high-dimensional machine-learning prediction tool to predict inpatient mortality, and compared the performance of this new tool to existing prediction indices. Methods: We identified cancer patients 75 and over who presented to an emergency department (ED) and were subsequently hospitalized from the National Emergency Department Sample (NEDS) between 2016 and 2018. We used an extreme gradient boosting approach to predict the risk of death during hospitalization. Model covariates included patient demographics, hospital characteristics, and International Classification of Diseases, version 10 (ICD-10) diagnosis codes recorded during the ED visit. The data were split 75%/25% into training/testing datasets. We constructed the model with training data and evaluated performance within the test data using area under the curve (AUC), with an AUC of 1.0 indicating perfect prediction. We compared the performance of this risk prediction model to standard prediction indices including the Hospital Frailty Risk Score, modified 5-item frailty index, and Charlson comorbidity index. Results: We identified 1,892,690 weighted-hospitalizations among elderly cancer patients, of which 133,379 (7.0%) who died in the inpatient setting. Our final predictive model included 238 features, which contained 5 demographic variables, 3 hospital characteristics, and 230 ICD-10 diagnosis codes. The predictive model achieved an AUC of 0.92. Our comparator models including the Hospital Frailty Risk Score, modified 5-item frailty index, and Charlson comorbidity index achieved AUCs of 0.67, 0.56, and 0.60, respectively. Conclusions: Using a high-dimensional machine-learning model enabled a high level of precision in predicting hospital mortality among elderly cancer patients, substantially out-performing existing prediction indices. High-dimensional prediction models show promise in helping to identify patients at risk of severe adverse outcomes, though additional validation is needed as well as research studying how to implement these tools into practice.

The 5-Factor Modified Frailty Index as a Predictor of 30-day Complications in Pressure Ulcer Repair

The 5-item modified frailty index (mFI-5) is a validated tool to assess postoperative risks in older surgical candidates. We sought to compare the predictive ability of mFI-5 to its individual components and other established risk factors for complications in flap reconstruction of late-stage pressure ulcer repair. The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for pressure ulcer diagnosis and reconstructive flap repair procedures. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status before surgery, diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, and history of hypertension requiring medicine), and other factors commonly used to risk-stratify (age, obesity, ASA classification, and history of smoking) were associated with complications. 35.1% of the total 1254 flap reconstructive procedures for pressure ulcer repair experienced complications. Most cases had at least one of the five mFI-5 factors in both the complication (42.7%) and no complication (45.7%) cohorts. Compared with the factors making up the mFI-5 score and other common variables used to risk-stratify, mFI-5 was significantly associated with complications in the univariate (OR 1.17, CI 1.03 - 1.33; P=0.02) and multivariate analysis (OR 1.16, CI 1.02 - 1.34; P=0.043). The mFI-5 is a useful predictor of postoperative outcomes in patients undergoing reconstructive flap surgery for pressure ulcer injuries compared to other historically considered risk factors for surgical complications.

Predicting nonroutine discharge in patients undergoing surgery for vertebral column tumors.

More than 8000 patients are treated annually for vertebral column tumors, of whom roughly two-thirds will be discharged to an inpatient facility (nonroutine discharge). Nonroutine discharge is associated with increased care costs as well as delays in discharge and poorer patient outcomes. In this study, the authors sought to develop a prediction model of nonroutine discharge in the population of vertebral column tumor patients. Patients treated for primary or metastatic vertebral column tumors at a single comprehensive cancer center were identified for inclusion. Data were gathered regarding surgical procedure, patient demographics, insurance status, and medical comorbidities. Frailty was assessed using the modified 5-item Frailty Index (mFI-5) and medical complexity was assessed using the modified Charlson Comorbidity Index (mCCI). Multivariable logistic regression was used to identify independent predictors of nonroutine discharge, and multivariable linear regression was used to identify predictors of prolonged length of stay (LOS). The discharge model was internally validated using 1000 bootstrapped samples. The authors identified 350 patients (mean age 57.0 ± 13.6 years, 53.1% male, and 67.1% treated for metastatic vs primary disease). Significant predictors of prolonged LOS included higher mCCI score (β = 0.74; p = 0.026), higher serum absolute neutrophil count (β = 0.35; p = 0.001), lower hematocrit (β = -0.34; p = 0.001), use of a staged operation (β = 4.99; p < 0.001), occurrence of postoperative pulmonary embolism (β = 3.93; p = 0.004), and surgical site infection (β = 9.93; p < 0.001). Significant predictors of nonroutine discharge included emergency admission (OR 3.09; p = 0.001), higher mFI-5 score (OR 1.90; p = 0.001), lower serum albumin level (OR 0.43 per g/dL; p < 0.001), and operations with multiple stages (OR 4.10; p < 0.001). The resulting statistical model was deployed as a web-based calculator (https://jhuspine4.shinyapps.io/Nonroutine_Discharge_Tumor/). The authors found that nonroutine discharge of patients with surgically treated vertebral column tumors was predicted by emergency admission, increased frailty, lower serum albumin level, and staged surgical procedures. The resulting web-based calculator tool may be useful clinically to aid in discharge planning for spinal oncology patients by preoperatively identifying patients likely to require placement in an inpatient facility postoperatively.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction.

Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction. The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded. A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related. Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.

A Case for the Use of the 5-Item Modified Frailty Index in Preoperative Risk Assessment for Tissue Expander Placement in Breast Reconstruction.

Preoperative risk assessment is essential in determining which surgical candidates will have the most to gain from an operation. The 5-item modified frailty index (mFI-5) has been validated as an effective way to determine this risk. This study sought to evaluate the performance of the mFI-5 as a predictor of postoperative complications after tissue expander placement. Patients who underwent placement of a tissue expander were identified using the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project database. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status, diabetes, chronic obstructive pulmonary disease, chronic heart failure, and hypertension), and other factors commonly used to risk stratify (age, body mass index [BMI], American Society of Anesthesiologists (ASA) classification, and history of smoking) were associated with complications. In 44,728 tissue expander placement cases, the overall complication rate was 10.5% (n = 4674). The mFI-5 score was significantly higher in the group that experienced complications (0.08 vs 0.06, P < 0.001). Compared with the mFI-5 individual components and other common variables used preoperatively to risk stratify patients, univariate analysis demonstrated that mFI-5 had the largest effect size (odds ratio [OR], 5.46; confidence interval [CI], 4.29-6.94; P < 0.001). After controlling for age, BMI, ASA classification, and history of smoking, the mFI-5 still remained the predictor of complications with the largest effect size (OR, 2.25; CI, 1.70-2.97; P < 0.001). In assessing specific complications, the mFI-5 is the independent predictor with the largest significant effect size for surgical dehiscence (OR, 12.76; CI, 5.58-28.18; P < 0.001), surgical site infection (OR, 6.68; CI, 4.53-9.78; P < 0.001), reoperation (OR, 5.23; CI, 3.90-6.99; P < 0.001), and readmission (OR, 4.59; CI, 3.25-6.45; P < 0.001) when compared with age, BMI, ASA class, and/or history of smoking alone. The mFI-5 can be used as an effective preoperative predictor of postoperative complications in patients undergoing tissue expander placement. Not only does it have the largest effect size compared with other historical perioperative risk factors, it is more predictive than each of its individual components.

Utility of the 5-Item Modified Frailty Index for Predicting Adverse Outcomes Following Elective Anterior Cervical Discectomy and Fusion

Frailty is an increasingly studied tool for preoperative risk stratification, but its prognostic value for anterior cervical discectomy and fusion (ACDF) patients is unclear. We sought to evaluate the association of the 5-item modified Frailty Index (5i-mFI) with 30-day adverse outcomes following ACDF and its predictive performance compared with other common metrics. The National Surgical Quality Improvement Program was queried from 2016-2018 for patients undergoing elective ACDF for degenerative diseases. Outcomes of interest included 30-day complications, extended length of stay (LOS), non-home discharge, and unplanned readmissions. Unadjusted/adjusted odds ratios were calculated. The discriminatory performance of the 5i-mFI compared with age, American Society of Anesthesiologists (ASA) classification, and body mass index was computed using the area under the receiver operating characteristic curve (AUC). A total of 23,754 patients were identified. On adjusted analysis, an index of 1 was significantly associated with extended LOS, non-home discharge, and unplanned readmissions (P < 0.001, P= 0.023, P= 0.003, respectively), but not complications (all P > 0.05). An index ≥2 was significantly associated with each outcome (all P < 0.001). The 5i-mFI was found to have a significantly higher AUC than body mass index for each outcome, a similar AUC compared with ASA classification and age for complications and unplanned readmissions, and a significantly lower AUC than ASA classification and age for extended LOS and non-home discharge. The 5i-mFI was found to be significantly associated with 30-day adverse outcomes following ACDF but had similar or lesser predictive performance compared with more universally available and easily implemented metrics, such as ASA classification and age.

Modified 5-Item Frailty Index Is Far More Predictive of Postoperative Adverse Outcomes than 14-Item Risk Analysis Index among Vascular Surgery Patients

Modified 5-Item Frailty Index Is Far More Predictive of Postoperative Adverse Outcomes than 14-Item Risk Analysis Index among Vascular Surgery Patients

5-Item Modified Frailty Index Predicts Outcomes After Below-Knee Amputation in the Vascular Quality Initiative Amputation Registry.

Patient frailty indices are increasingly being utilized to anticipate post-operative complications. This study explores whether a 5-factor modified frailty index (mFI-5) is associated with outcomes following below-knee amputation (BKA). All BKAs in the vascular quality initiative (VQI) amputation registry from 2012-2017 were reviewed. Preoperative frailty status was determined with the mFI-5 which assigns one point each for history of diabetes, chronic obstructive pulmonary disease or active pneumonia, congestive heart failure, hypertension, and nonindependent functional status. Outcomes included 30-day mortality, unplanned return to odds ratio (OR), post-op myocardial infarction (MI), post-op SSI, all-cause complication, revision to higher level amputation, disposition status, and prosthetic use. 2040 BKAs were performed. Logistic regression showed an increasing mFI-5 score that was associated with higher risk of combined complications (OR 1.22, confidence interval [CI] 1.07-1.38, P < .05), 30-day mortality (OR 1.60, CI 1.19-2.16, P < .05), post-op MI (OR 1.79, CI 1.30-2.45, P < .05), and failure of long-term prosthetic use (OR 1.17, CI 1.03-1.32, P < .05). In the VQI, every one-point increase in mFI-5 is associated with an increased risk of 22% for combined complications, 60% for 30-day mortality, nearly 80% for post-op MI, and 17% for failure of prosthetic use in BKA patients. The mFI-5 frailty index should be incorporated into preoperative planning and risk stratification.

Admission neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio to predict 30-day and 1-year mortality in geriatric hip fractures

IntroductionElderly patients with hip fractures exhibit a high incidence of mortality and morbidity. The aim of this study was to evaluate the factors that may predict mortality in patients with geriatric hip fracture. MethodsIncluded in this retrospective study were 241 patients who were admitted to the hospital with hip fractures between May 2017 and March 2019. The effect of the modified 5-item frailty index (mFI-5) on 30-day and 1-year mortality was evaluated. In addition, admission neutrophil-to-lymphocyte ratios (NLRs) and monocyte-to-lymphocyte ratios (MLRs) were also examined. ResultsThe mFI-5 was not found to be a statistically significant predictive indicator for 30-day and 1-year mortality (P = 0.485 and P = 0.484, respectively). Chronic obstructive pulmonary disease or current pneumonia was found to increase mortality by 2.702 times (P = 0.002). The 30-day mortality rates of patients aged ≥80 years were significantly higher than those aged 65–79 years (P < 0.05). However, there was no statistical difference in the mortality rates between the age groups after 30 days postoperatively (P = 0.114). Admission NLRs and MLRs were significantly higher in the 30-day and 1-year mortality groups. The cut-off values of the admission NLRs and MLRs for 30-day mortality were calculated as 6.55 and 0.65, respectively, while the same cut-off values for 1-year mortality were calculated as 6.55 and 0.635, respectively. ConclusionsAdmission NLRs and MLRs are useful hematological data for the prediction of 30-day and 1-year mortality in geriatric hip fracture patients.

Modified Frailty Index Predicts Postoperative Complications following Panniculectomy in the Elderly.

Background:Due to the high complication rate of panniculectomies, preoperative risk stratification is imperative. This study aimed to assess the predictive value of the 5-item modified frailty index (mFI-5) for postoperative complications in the elderly following panniculectomy.Methods:A retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database for patients over the age of 65 years who underwent a panniculectomy between 2010 and 2015 was conducted. The mFI-5 score was calculated for each patient based on the presence of diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status, and an mFI-5 score of 2 was used as a cutoff. Multivariate logistic and linear regression analysis was used to determine the validity of the mFI-5 as a predictor of postoperative complications.Results:A total of 575 patients were analyzed. Patients with an mFI-5 score of 2 or more (421; 73.2%) had significantly higher rates of wound complications (19.5% versus 12.8%; P = 0.03), overall complications (33.8% versus 19.5%; P < 0.001), and significantly longer hospital length of stay (3.6±5.0 versus 1.9±3.0; P < 0.001). mFI-5 score of 2 or more was an independent risk factor for wound complications (odds ratio, 1.26; 95% confidence interval, 1.08–2.20; P = 0.04) and overall complications (odds ratio, 1.34; 95% confidence interval, 1.09–2.15; P = 0.02).Conclusions:Frailty, as measured by the mFI-5, holds a predictive value regarding outcomes of wound complications and overall complications in elderly patients after panniculectomy. The mFI-5 score can be used to identify high-risk patients before surgery.

The 5-Item Modified Frailty Index Predicts Adverse Outcomes in Trauma

BackgroundThe 5-item modified frailty index (mFI-5) has been shown to predict adverse outcomes in surgery; yet, its role in trauma patients is unclear. We hypothesized that increasing frailty, as indicated by increasing mFI-5 scores, would correlate with worse outcomes and greater mortality in trauma patients. MethodsWe performed a retrospective review of patients captured by our 2018 Spring and Fall Trauma Quality Improvement Program registry. The mFI-5 was calculated by assigning one point for each comorbidity present: diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Outcomes included complications, length of stay, mortality, and discharge location. ResultsA total of 3364 patients were included; 68.0% (n = 2288) were not frail, 16.5% (n = 555) were moderately frail, and 15.5% (n = 521) were severely frail. Higher frailty scores were associated with greater rates of unplanned intubations (P < 0.01) and unplanned admissions to the intensive care unit (P < 0.01). Rates of nonhome discharge (P < 0.0001) were significantly higher in the severe frailty group compared with the moderate and no frailty groups. On multivariable regression adjusting for demographics and injury details, severe frailty was predictive of any complication (odds ratio [OR], 1.53; 95% confidence interval [95% CI], 1.12-2.11; P < 0.01), failure to rescue (OR, 2.88; 95% CI, 1.47-5.66; P = 0.002), nonhome discharge (OR, 1.88; 95% CI, 1.47-2.40; P < 0.0001), and mortality (OR, 1.83; 95% CI, 1.07-3.15; P = 0.03). ConclusionsFrailty is not only associated with longer hospitalizations but also with more complications, adverse discharge locations, and increased odds of mortality. The mFI-5 is a quick and intuitive tool that can be used to determine an individual's frailty at the time of admission.

Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty

BackgroundThe demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient. MethodsThis is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts. Results105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001). ConclusionsFrailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.

Post-operative outcomes for patients with liver-related ascites undergoing non-emergent laparoscopic cholecystectomy

Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy. The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index. 346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%, p = 0.0039), mortality (3.6% vs. 1.5%, p = 0.0020), and longer hospitalizations (7.4 vs. 4.4days, p < 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (p = 0.1124) or mortality (p = 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%, p = 0.0056) and mortality (7.1%, p = 0.0333). Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.

The Impact Of Frailty On Patients Undergoing Liver Resection For Colorectal Liver Metastasis: A Review Of The National Surgical Quality Improvement Program

Presenter: Jacqueline Dauch MD | University of Arizona Background: Frailty is highly prevalent in patients with malignancy and is associated with high risk of morbidity and mortality after operative interventions. However, the impact of frailty on patients undergoing liver resection for metastatic colorectal cancer has not been studied. The aim of this study was to assess the impact of frailty on short term outcomes after liver resection in patients with metastatic colorectal cancer to the liver. Methods: We performed a 4 year analysis of the National Surgical Quality Improvement Program (NSQIP) participant user files. All patients undergoing hepatectomy for metastatic colorectal cancer between 2014-2017 were reviewed. The 5-item Modified Frailty Index (mFI) was calculated using NSQIP variables. We included all patients with complete mFI information in the analysis. Patients were divided into three categories based on the mFI (0= no frailty indicators, 1=one frailty indicator, 2=two or more frailty indicator). Outcome measures in house included minor and major morbidity as defined by the Clavien-Dindo classification (I/II vs III/IV), 30 day mortality, need for readmission, unfavorable discharge (not to home), bile leak and liver failure. Results: A total of 5230 patients were included in the analysis. 2737 (52%) had a mFI score of 0, 1839 (35%) had a mFI score of 1, and 654 (13%) had a mFI score of 2 or more. On multivariate analysis and after adjusting for potential cofounders such as age, sex, race/ethnicity, BMI, ASA class, preoperative albumin, neoadjuvant chemotherapy and extent of surgery (minor vs major ); patients with a mFI score of 2 or over were more likely than those with mFI of 0 to experience minor morbidity (OR 1.47, 95% CI 1.14-1.91, p<0.01), major morbidity (OR 1.82, 95% CI 1.29-2.55, p<0.01), readmission (OR 1.56 95% CI 1.10-2.23, p<0.01), non-home discharge (OR 2.81, 95% CI 1.74-4.50, p<0.01), and bile leak (OR 1.64 95% CI.05-2.54, p=0.03). Those with a mFI score of 1 were more likely than those with mFI 0 to experience non-home discharge (OR 1.54 95% CI 1.03-2.31 p=0.04) and liver failure (OR 1.63, 95% CI 1.14-2.45, p<0.01). Conclusion: Frailty is associated with increased risk of morbidity, unfavorable discharge, readmission and bile leak in patients undergoing liver resection for metastatic colorectal cancer. We recommend the use of the 5-item Modified Frailty Index to guide risk stratification, optimization and counseling.

The 5-Item Modified Frailty Index Is Predictive of Severe Adverse Events in Patients Undergoing Surgery for Adult Spinal Deformity.

A retrospective review of 281 consecutive cases of adult spine deformity (ASD) surgery (age 55 ± 19 yrs, 91% female, follow-up 4.3 ± 1.9 yrs) from a multicenter database. To compare the value and predictive ability of the 5-item modified frailty index (mFI-5) to the conventional 11-item modified frailty index (mFI-11) for severe adverse events (SAEs). Several recent studies have described associations between frailty and surgical complications. However, the predictive power and usefulness of the mFI-5 have not been proven. SAEs were defined as: Clavien-Dindo grade >3, reoperation required, deterioration of motor function at discharge, or new motor deficit within 2 years. The patients' frailty was categorized by the mFI-5 and mFI-11 (robust, prefrail, or frail). Spearman's rho was used to assess correlation between the mFI-5 and mFI-11. Univariate and multivariate Poisson regression analyses were conducted to analyze the relative risk of mFI-5 and mFI-11 as a predictor for SAEs in ASD surgery. Age, sex, and baseline sagittal alignment (Schwab-SRS classification subcategories) were used to adjust the baseline variance of the patients. Of the 281 patients, 63 (22%) had developed SAE at 2 years. The weighted Kappa ratio between the mFI-5 and mFI-11 was 0.87, indicating excellent concordance across ASD surgery. Frailty was associated with increased total complications, perioperative complications, implant-related complications, and SAEs. Adjusted and unadjusted models showed similar c-statistics for mFI-5 and mFI-11 and a strong predictive ability for SAEs in ASD surgery. As the mFI-5 increased from 0 to ≥2, the rate of SAEs increased from 17% to 63% (P < 0.01), and the relative risk was 2.2 (95% CI: 1.3-3.7). The mFI-5 and the mFI-11 were equally effective predictors of SEA development in ASD surgery. The evaluation of patient frailty using mFI-5 may help surgeons optimize procedures and counsel patients. 4.

PC066. Preoperative Functional Status Predicts Risk of Within-30-Day Stroke/Death After Carotid Artery Stenting Better Than 5-Item Modified Frailty Index

PC066. Preoperative Functional Status Predicts Risk of Within-30-Day Stroke/Death After Carotid Artery Stenting Better Than 5-Item Modified Frailty Index

Compliance to an enhanced recovery pathway among patients with a high frailty index after major gastrointestinal surgery results in improved 30-day outcomes

BackgroundEnhanced recovery pathways have been shown to improve clinical outcomes after surgery. Concerns exist about the feasibility of implementing enhanced recovery pathways in frail patients, who are at a greater risk for adverse postoperative outcomes. This study evaluated compliance and outcomes after enhanced recovery pathway implementation in high-risk, abdominal surgery patients. MethodsPatients entered into the American College of Surgeons National Surgical Quality Improvement Program database who underwent abdominal surgery after enhanced recovery pathway implementation at two Johns Hopkins Medical Institutions were included. Risk was assessed using the American College of Surgeons National Surgical Quality Improvement Program validated, modified 5-item frailty index. Primary outcomes included compliance with 14 enhanced recovery pathway standards and postoperative length of stay, major complications (Clavien-Dindo score II–IV), and 30-day readmission. ResultsThis study included 646 patients who participated in our enhanced recovery pathway program and 65 patients with modified 5-item frailty index ≥ 2 before enhanced recovery pathway implementation. Overall, 325 patients (50.3%) were high compliers (>75% compliance) with enhanced recovery pathway standards, with similar proportions of patients with a modified 5-item frailty index ≥ 2 or < 2 achieving high compliance (51.6% vs 50.2%, P = .89, respectively). Examining causality for “low compliers” among patients with a high frailty score (modified 5-item frailty index ≥2) demonstrated significant less use of goal-directed therapy when compared with “high compliers” (43% vs 75%, P = .01). Low compliers were also less likely than high compliers to experience mobilization the day of surgery (43% vs 78%, P = .01), postoperative day 1 (43% vs 88%, P < .01), and postoperative day 2 (60% vs 100%, P < .01). In addition, low compliers were less likely than high compliers to have their diet advanced to solids on postoperative day 1 (17% vs 59%, P < .01) and have their Foley catheter removed on postoperative day 1 (45% vs 97%, P < .01). Comparing our pre-enhanced recovery pathway patients with our enhanced recovery pathway cohort with a high frailty score, enhanced recovery pathway patients had a significantly shorter length of stay (4.5 vs 6 days, P = .04). However, adjusted analysis demonstrated that high compliance, and not just the enhanced recovery pathway intervention among patients with a high frailty score, was independently associated with a decrease in length of stay (odds ratio 0.72, 95% confidence interval 0.63–0.82, P < .01) and a significant reduction in major complications (odds ratio 0.30, 95% confidence interval 0.14–0.65, P < .01. ConclusionThis study demonstrates that frail patients comply well with a robust enhanced recovery pathway protocol and subsequently experience improved outcomes. Targeted interventions that seek to maximize compliance with specific enhanced recovery pathway standards may further improve outcomes in this population.