Clinical Groups Frailty-defining Diagnoses Indicator Research Articles

A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty.

Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations. We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world. In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding). Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well. Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.

D-20 | Impact of Frailty on Outcomes of Percutaneous Coronary Intervention: Insights from the Nationwide Inpatient Sample

Patients with significant coronary artery disease require percutaneous coronary intervention (PCI). However, whether frailty has adverse outcomes in patients undergoing PCI has been controversial. We investigated the impact of frailty on the outcomes of patients who underwent PCI. We reviewed the National Inpatient Sample to identify patients that underwent PCI. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Univariate and multivariate logistic regression analyses were performed to determine any association between frailty and the clinical outcomes. From 2017-2020, 102,324 patients underwent PCI in the United States, and 7.3% met the criteria for frailty. We found that the frail group had longer lengths of stay (10 vs 4 days, p < 0.001), and higher hospitalization costs ($266k vs $158k, p < 0.001). After multivariate adjustment, we found that frailty was associated with increased in-hospital mortality, cardiogenic shock, increased vasopressor requirements, higher need for mechanical circulatory support, higher need for mechanical ventilation, increased incidence of post-operative stroke and post-operative sepsis, and increased risk of sudden cardiac death. The presence of frailty in patients who underwent PCI was associated with significantly higher in-hospital mortality, longer lengths of stay, higher hospitalization costs, and worsening secondary outcomes. These findings may suggest the need for an alternative approach for frail patients who are indicated for revascularization.

Association between frailty status and complications in patients undergoing surgical excision of malignant esophageal neoplasms.

Research within the last decade highlights the patients' frailty status as an important predictor of esophageal cancer outcomes, but the literature evaluating frailty's role in these patients remains limited. We evaluated the role of frailty in patients undergoing resection of malignant esophageal neoplasms. We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients who underwent excision of a malignant esophageal neoplasm. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Propensity score matching identified 289 frail patients and 281 non-frail patients. Mann-Whitney U testing was performed and receiver operating characteristic (ROC) curves were created, following the creation of logistic regression models for predicting discharge disposition. The area under the curve (AUC) served as a proxy for model performance. Frail patients had significantly more nonroutine discharges, longer inpatient lengths of stay, higher costs, more acute infections, posthemorrhagic anemia and deep vein thrombosis, and greater mortality (P<0.05). No significant differences were found between the 2 cohorts with respect to readmission rates, pulmonary embolism or dysphagia. Predictive models for patient discharge disposition demonstrated that frailty status in combination with age resulted in better ROC curves (AUC: 0.652) compared to models using age alone (AUC: 0.601). Frailty was found to be significantly correlated with higher rates of inpatient medical complications following esophagectomy. The inclusion of patient frailty status in predictive models for discharge disposition resulted in a better predictive capacity compared to those using age alone.

Association Between Frailty, 30-day Unplanned Readmission and Mortality After Hospitalization for Heart Failure: Results From the Nationwide Readmissions Database.

Objectives: This study examined how frailty in traditional risk-adjusted models could improve the predictability of unplanned 30-day readmission and mortality among heart failure patients. Methods: This study was a retrospective analysis of Nationwide Readmissions Database data collected during the years 2010-2018. All patients ≥65years who had a principal diagnosis of heart failure were included in the analysis. The Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator was used to identify frail patients. Results: There was a total of 819,854 patients admitted for heart failure during the study period. Among them, 63,302 (7.7%) were frail. In the regression analysis, the risk of all-cause 30-day readmission (OR, 1.18; 95% CI, 1.14-1.22) and in-hospital mortality (OR, 1.52; 95% CI, 1.40-1.66) were higher in patients with frailty. Discussion: Inclusion of frailty in comorbidity-based risk-prediction models significantly improved the predictability of unplanned 30-day readmission and in-hospital mortality.

Comparing the predictive accuracy of frailty instruments applied to preoperative electronic health data for adults undergoing noncardiac surgery

BackgroundPreoperative frailty is associated with increased risk of postoperative mortality and complications. Routine preoperative frailty assessment is underperformed. Automation of preoperative frailty assessment using electronic health data could improve adherence to guideline-based care if an accurate instrument is identified. MethodsWe conducted a retrospective cohort study of adults >65 yr undergoing elective noncardiac surgery between 2012 and 2018. Four frailty instruments were compared: Frailty Index, Hospital Frailty Risk Score, Risk Analysis Index-Administrative, and Adjusted Clinical Groups frailty-defining diagnoses indicator. We compared the predictive performance of each instrument added to a baseline model (age, sex, ASA physical status, and procedural risk) using discrimination, calibration, explained variance, net reclassification, and Brier score (binary outcomes); and explained variance, root mean squared error, and mean absolute prediction error (continuous outcomes). Primary outcome was 30-day mortality. Secondary outcomes included 365-day mortality, length of stay, non-home discharge, days alive at home, and 365-day costs. ResultsFor this study, 171 576 patients met the inclusion criteria; 1370 (0.8%) died within 30 days. Compared with the baseline model predicting 30-day mortality (area under the curve [AUC] 0.85; R2 0.08), the addition of Hospital Frailty Risk Score led to the greatest improvement in discrimination (AUC 0.87), explained variance (R2 0.09), and net reclassification (Net Reclassification Index 0.65). Brier and calibration scores were comparable. ConclusionsAll four frailty instruments significantly improved discrimination and risk reclassification when added to typically assessed preoperative risk factors. Accurate identification of the presence or absence of preoperative frailty using electronic frailty instruments may improve perioperative risk stratification. Future research should evaluate the impact of automated frailty assessment in guiding surgical planning and patient-centred optimisation amongst older surgical patients.

Impact of Frailty on Outcomes After Transcatheter Edge-to-Edge Repair With MitraClip (from the National Inpatient Sample Database)

Transcatheter edge-to-edge repair (TEER) with MitraClip (Abbott, Santa Clara, California) is a frequently chosen method for mitral valve repair for patients at high surgical risk. We investigated the impact of frailty on outcomes of patients who underwent TEER. We reviewed the National Inpatient Sample to identify patients that underwent TEER with MitraClip. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. The primary end point was in-hospital mortality. The secondary end points included blood transfusion, respiratory failure, sepsis, length of stay, and total hospitalization cost. Univariate and multivariate logistic regression analyses were performed to determine any association between frailty and primary or secondary outcomes. From January 2016 to December 2017, 10,055 patients underwent TEER in the United States, and 10.6% of them met the criteria for frailty. The frail group showed increased in-hospital mortality (7.04% vs 1.61%, p&lt;0.001) and respiratory failure (3.75% vs 0.95%, p&lt;0.001). Similarly, the frail group had longer lengths of stay (6 vs 2days, p&lt;0.001) and higher hospitalization costs ($224.8k vs $180.9k, p&lt;0.001). After multivariable logistic regression analysis, frailty was associated with increased in-hospital mortality (odds ratio [OR] 3.70, 95% confidence interval [CI] 1.91 to 7.18, p&lt;0.001), transfusion (OR 1.85, 95% CI 1.07 to 3.19, p=0.029), respiratory failure (OR 3.56, 95% CI 1.48 to 8.52, p=0.005), and sepsis (OR 4.17, 95% CI 1.84 to 9.46, p=0.001). In conclusion, frailty was present in about 10% of patients who underwent TEER from 2016 to 2017. The presence of frailty was associated with worse in-hospital outcomes and greater resource use.

The Impact of Frailty Syndrome on Endogenous Endophthalmitis Development and Outcomes: A Population-Level Analysis

Characterize the impact of frailty on endogenous endophthalmitis (EE) development and clinical outcomes among septicemic patients. Population-level, retrospective cohort study. Adult inpatients within the National Inpatient Sample (years 2002-2014) diagnosed with bacterial septicemia. Septicemic patients were classified as frail or nonfrail using the previously validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, and diagnosis of EE was abstracted from International Classification of Diseases 9 codes. We used multivariable logistic regression to generate odds ratios (ORs) for rates of EE development and in-hospital mortality based on frailty status. We also examined the association between frailty and blood culture-proven organism class, inpatient length of stay, and total charges billed to insurance. Incidence of EE among septicemic patients; rates of EE development among frail and nonfrail patients; blood culture-proven microbe type, length of stay, and total charges billed to insurance. 9294 of 18 470 658 (0.05%) inpatients with bacteremia developed EE, 2102 (22.6%) of whom had at least 1 frailty-defining feature (predominantly malnutrition [68%]). Odds of developing EE were 16.7% higher for frail patients (OR, 1.167; 95% confidence interval, 1.108-1.229) when controlling for age, sex, race, concomitant human immunodeficiency virus/AIDS, pyogenic liver abscess, infectious endocarditis, cirrhosis, and diabetes with chronic complications. Frail EE patients had a 27.9% increased odds of in-hospital death, independent of age, sex, race, and Elixhauser comorbidity score (OR, 1.279; 95% confidence interval, 1.056-1.549). Higher rates of methicillin-resistant Staphylococcus aureus bacteremia (14.3% vs. 10.9%, P= 0.000016), gram-negative bacteremia (7.6% vs. 4.9%, P= 0.000003), and concomitant candidemia (10.4% vs. 7.0%, P = 0.0000004) were associated with frailty. Hospital stays were significantly longer (median, 14 days; interquartile range, 19 days; P < 0.00001) and total charges billed to insurance were significantly greater (median, $96 398; interquartile range, $154,682; P < 0.00001) among frail EE patients. Frailty syndrome is independently associated with development of EE in the setting of bacterial septicemia; frailty-associated EE may occur in patients with malnutrition and particular bacterial subtypes, and it predisposes to higher rates of in-hospital death and health care resource usage.

Frailty is independently associated with worse outcomes and increased resource utilization following endometrial cancer surgery

ObjectiveFrailty has been associated with poorer surgical outcomes and is a critical factor in procedural risk assessment. The objective of this study is to assess the impact of frailty on...

Management and Outcomes of ST-Segment Elevation Myocardial Infarction in Hospitalized Frail Patients in the United States

Cardiovascular diseases and frailty are common conditions of aging populations and often coexist. In this study, we examined the in-hospital management, outcomes, and resource use of frail patients hospitalized for ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of the 2005-2014 data from the Nationwide Inpatient Sample. Patients were classified into to versus 'nonfrail' using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome was STEMI management, whereas secondary outcomes were in-hospital mortality, length of stay, and cost. Outcomes were compared between frail and nonfrail patients using propensity score-matched analysis. There were 1,360,597 STEMI hospitalizations, of which 36,316 (2.7%) were frail. Propensity score-matched analysis showed that in in-hospital management options for STEMI, the odds of overall revascularization (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55 to 0.65), percutaneous coronary intervention (OR, 0.53; 95% CI, 0.49 to 0.57), and coronary angiography (OR, 0.59; 95% CI, 0.55 to 0.64) were significantly lower for frail patients. The odds of receiving coronary artery bypass grafting (OR, 1.66; 95% CI, 1.48 to 1.86) and overall hemodynamic support (OR, 1.26; 95% CI, 1.15 to 1.39) were significantly higher for frail patients. In-hospital mortality (18.7% vs 8.2%, p <0.001), length of stay (7.7 vs 3.7 days, p <0.001) and costs ($90,060 vs $63,507, p <0.001) were significantly higher in frail patients. Our findings suggest that collaborative efforts by cardiologists and cardiovascular surgeons for identifying frailty in patients with STEMI and incorporating frailty in risk estimation measures may improve management strategies, resource use and optimize patient outcomes.

Association Between Frailty and 30-day Unplanned Readmission After Hospitalization for Heart Failure: Results from Nationwide Readmissions Database

<h3>Purpose</h3> Frailty is associated with adverse hospital outcomes in heart failure (HF) patients. This study examines the association between frailty, readmission, and other relevant hospital outcomes using a national database. <h3>Methods</h3> This is a retrospective analysis of the Nationwide Readmissions Database from 2010 to 2014. Patients ≥65 years of age admitted for HF were included in the study. We used the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome of the study was 30-day unplanned readmission rate. <h3>Results</h3> A total of 819,854 patients were admitted for HF, of which 63,302 (7.7%) were frail. Frail patients, 22,382 (35.4%) experienced unplanned readmission within 30 days after index hospitalization, as compared to non-frail patients, 168,797 (22.3%, P<0.001). Trend analysis showed that the relative decrease rates of unplanned 30-day readmission decreased for both frail (7.8%) and non-frail (6.9%) patients during the study period. Among HF patients who experienced unplanned 30-day readmission, mortality rates (16.2% versus 8.2%, P<0.001) and hospitalization cost ($13,616 versus $9,876, P<0.001) were higher among frail patients, compared to non-frail patients. Besides HF, most common reasons for unplanned 30-day readmission among frail HF patients were septicemia (11.2%), and acute renal failure (5.1%). Regression analysis showed that the risk for unplanned 30-day readmission was higher in patients with frailty (OR, 1.18; 95% CI, 1.14-1.22). Other risk factors for unplanned 30-day readmission were comorbidity index >3, AMI, CAD, arrhythmia, diabetes mellitus, cancer, chronic lung disease, chronic renal disease, liver disease, fluid and electrolyte disorder, anemia, coagulation disorder, and vasopressor use. <h3>Conclusion</h3> Frailty among elderly patients hospitalized for HF is associated with increased readmission, mortality, and cost. Identifying frailty in this population could improve quality of care and decrease hospital burden.

Association of Frailty with Perioperative Outcomes Following Hepatic Resection: A National Study.

Risk of mortality and major comorbidity remains high following hepatic resection. Given recent advancements in nonsurgical techniques to control hepatic malignancy, accurate assessment of surgical candidates, especially those considered frail, has become imperative. The present study aimed to characterize the impact of frailty on clinical and financial outcomes following hepatic resection in older individuals. Retrospective cohort study. All older adults (≥65years) undergoing elective hepatic resection were identified from the 2012 to 2019 National Inpatient Sample. Frailty was defined by using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Multivariable regression models were developed to assess the independent association of frailty with mortality, perioperative complications, and resource utilization. Marginal effects were tabulated to assess the impact of hospital volume on frailty-associated mortality. Of an estimated 40,735 patients undergoing major hepatic resection, 9.0% were considered frail. After multivariable adjustment, frailty was associated with increased odds of mortality (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 2.0-4.3; P < .001) and perioperative complication (AOR 2.9; 95% CI 2.4-3.4; P < .001). Furthermore, frail patients incurred longer risk-adjusted length of stay (14.2 vs 6.7days, P < .001) and greater hospitalization costs ($55,100 vs $29,300, P < .001). In assessing the impact of institutional expertise on perioperative outcomes, the marginal effect of frailty on mortality became less pronounced with increasing operative volume. As the population of the United States continues to age, surgeons are increasingly likely to encounter candidates for major hepatic resection who are frail. The present study associated frailty with inferior clinical and financial outcomes; however, frailty-associated mortality became less pronounced at centers with high hepatic resection operative volume. Coding-based instruments, such as the Johns Hopkins Adjusted Clinical Groups, may identify patients from electronic medical records who may benefit from further geriatric assessment and targeted treatments.

Impact of Frailty on Hospital Outcomes Among Patients with Lymphoid Malignancies Receiving Autologous Hematopoietic Stem Cell Transplantation in the United States

BackgroundFrailty could affect outcomes of autologous hematopoietic stem cell transplantation (aHSCT). This study sought to examine the effects of frailty on hospital outcomes among patients with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), and multiple myeloma (MM) who received aHSCT. Materials and MethodsThis study was a retrospective analysis of Nationwide Inpatient Sample database, 2005 to 2014. Outcome variables were in-hospital mortality, prolonged length of stay and hospitalization cost. Frail patients were defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. ResultsThere were 20,573 NHL, 8,974 HL, and 40,750 MM patients. Among them, 5.5% NHL, 3.8% HL, and 4.8% MM patients were frail. Among patients with NHL, there were significant associations between frailty and in-hospital mortality (Odds Ratio [OR], 4.04, 95% CI: 2.11-7.76), and prolonged length of stay (OR, 2.32, 95% CI: 1.56-3.46). Similarly, among HL, there were significant associations between frailty and in-hospital mortality (OR, 1.82, 95% CI: 1.43-2.76), and prolonged length of stay (OR, 1.55, 95% CI: 1.34-2.84). Likewise, for MM, there were significant associations between frailty and in-hospital mortality (OR, 4.28, 95% CI: 2.16-8.48), and prolonged length of stay (OR, 3.00, 95% CI: 2.00-4.51). These associations remained significant after stratifying by age and comorbidities. Significant differences were observed in hospitalization cost between frail and non-frail patients. ConclusionAmong patients with lymphoid malignancies undergoing HSCT, frailty was associated with greater in-hospital mortality, longer length of stay, and higher hospitalization costs. Comprehensive health status assessments for identifying and managing frail patients in this population could improve patient outcomes.

The Pragmatic Impact of Frailty on Outcomes of Coronary Artery Bypass Grafting

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG). Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression. Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P= .002), while annual mortality rates declined (nonparametric test for trend P <.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P < .001), and more commonly female (32.8% vs 26.2%, P < .001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P < .001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P < .001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P < .001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P < .001). Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

P47. The association of patient frailty increased complication and readmission rates after lumbar spinal fusion surgery

BACKGROUND CONTEXT Frailty is a clinically relevant state that is often found in geriatric patients. Frail patients often have increased complications and mortality rates when undergoing invasive procedures such as lumbar spinal fusion, yet literature outlining the association between frailty and post-fusion complications is absent. As the prevalence of frail patients continues to grow, a thorough analysis of their perioperative characteristics and complications is necessary to guide the safest route of surgical care. PURPOSE Here, we utilize predictive analytics to evaluate the role of frailty on the postoperative course of lumbar spinal fusion patients. STUDY DESIGN/SETTING Retrospective cohort analysis using the 2010-2016 National Readmission Database. PATIENT SAMPLE Using the 2010-2016 National Readmission Database, we conducted a retrospective cohort analysis of 596,568 patients who received a lumbar spinal fusion procedure. From this cohort, 22,624 patients were found to be frail. OUTCOME MEASURES Postoperative complications, associated surgical costs, inpatient length of stay, and readmission at 30- and 90-days. METHODS Frail patients were identified using ICD-9 codes, ICD-10 codes, and the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We used propensity score matching to obtain a group of 22,624 non-frail, one-to-one age and sex matched, control patients from the initial lumbar spinal fusion cohort for comparison. Data was collected for those readmitted within 30 and 90 days, and all patients with routine or elective follow-ups were excluded. Statistics were conducted using RStudio, and predictive algorithms were developed using generalized gaussian logistic regression models. Significance was determined by Welch Two Sample t-testing, Tukey multiple comparison of means, and Wald testing. RESULTS The average age of the frail cohort was 63.76 years, and the average age of the propensity matched control group was 63.67 years at the time of lumbar fusion. The percent of female patients in the frailty and control groups were 55.6% and 56.5% respectively. Fragile patients had significantly higher total charges associated with their primary lumbar fusion procedure ($207,347.00±200,717.30) compared to those in the control group ($122,202.80±99,937.70) (p CONCLUSIONS Frailty has a significant influence on the postsurgical course of patients receiving lumbar spinal fusion. Not only does patient frailty increase the frequency and number of readmissions, but it also seems to be correlated with an increase in postoperative complications. Further long-term research is required to truly understand the comprehensive effects of frailty on patients receiving spinal fusion. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Role of Frailty in Failure to Rescue After Cardiovascular Surgery

Failure to rescue (FTR) is gaining popularity as a quality metric. The relationship between patient frailty and FTR after cardiovascular surgery has not been fully explored. This study aimed to utilize a national database to examine the impact of patient frailty on FTR. Of 5,199,534 patients undergoing cardiovascular surgery between 2000 and 2014, 75,851 (1.5%) were identified from the Nationwide Inpatient Sample database as frail based on the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Propensity-score matching was used to adjust for patient- and hospital-level characteristics and comorbidities when comparing frail and nonfrail patients. Frail patients were on average older (68 ± 12 years vs 65 ± 12 years; P < .001) and had more comorbidities including heart failure, and chronic lung, liver, or renal disease. Among 68,472 matched pairs, frail patients had significantly higher rates of FTR (13.4% vs 11.9%; P<.001). This contributed to a $39,796 increase in cost per hospitalization (P < .001). Renal failure, respiratory failure, pneumonia, and sepsis were most commonly associated with FTR in frail patients. When hospitals were stratified by risk-adjusted mortality, low-mortality (1st quintile) centers had significantly lower FTR rates and costs among frail patients when compared to high-mortality (5th quintile) centers. Frailty contributes significantly to FTR after cardiovascular surgery. Frail patients can expect better outcomes with lower costs at cardiac surgical centers of excellence that can adequately manage postoperative outcomes. Preoperative assessment of frailty may better guide risk estimation and identification of patients who would benefit from appropriate prehabilitative interventions to optimize outcomes.

Volume of frail patients predicts outcome in frail patients after cardiac surgery

ObjectiveRecent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this “frailty volume-frailty outcome relationship” in patients undergoing cardiac surgery. MethodsWe studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. ResultsIn comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. ConclusionsIn frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the “frailty volume-outcome relationship” superseded the traditional “volume-outcome relationship” in frail patients with cardiac disease.

Effects of Frailty on Outcomes and 30-day Readmissions After Surgical Mitral Valve Replacement

Frailty is increasingly recognized as an important prognostic marker in surgical populations. The effects of frailty on outcomes after mitral valve replacement (MVR) is less clear given the inherent complexity of this patient population. We evaluated the influences of frailty on outcomes and readmission rates after MVR. Adult patients undergoing isolated MVR were queried from the National Readmissions Database from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, a validated instrument developed for use in health administrative data. Multivariable logistic regression was used to determine hospital- and patient-level risk factors for readmission, postoperative complications, and death. Among 50,410 patients who underwent MVR, 7.9% met frailty criteria. Frail patients were more likely to be older, have nonprivate insurance, an index admission from the emergency department, and teaching hospital care (all P < .001). Frail patients had significantly more postoperative complications (77% vs 47%, P < .001), more discharges to a facility (50% vs 21%, P < .001), and higher in-hospital mortality (12% vs 4%, P < .001). Index hospitalization costs were almost doubled in frail patients, and of those who survived to discharge, 30-day readmissions were more frequent (28% vs 20%, P < .001). Frailty independently increased the risk of index hospitalization composite complications (adjusted odds ratio [AOR], 3.28; 95% confidence interval [CI], 2.61-4.12), in-hospital mortality (AOR, 2.35; 95% CI, 1.90-2.92), and 30-day readmission (AOR, 1.47; 95% CI, 1.20-1.78). Frailty is an independent predictor of morbidity, death, and increased costs after MVR. Frailty metrics should be increasingly understood among patients requiring mitral valve intervention as percutaneous approaches for intervention become increasingly used.

Is Frailty Associated With Worse Outcomes After Head and Neck Surgery? A Narrative Review.

Frailty has emerged as an important determinant of many health outcomes across various surgical specialties. We examined the published literature reporting on frailty as a predictor of perioperative outcomes in head and neck cancer (HNC) surgery. Narrative review with limited electronic database search and cross-referencing of included studies. PubMed was searched from inception until June 2019 to capture studies evaluating an association between frailty and perioperative outcomes among patients undergoing HNC surgery. Primary outcomes included mortality and morbidity, whereas secondary outcomes included in-hospital cost, length of stay, readmission, and discharge disposition. We identified nine series examining frailty as a predictor of outcomes in HNC. The majority of studies (77%) identified patients using a large population-based database such as the National Surgical Quality Improvement Project or National Inpatient Sample. Frailty measures applied in the HNC surgery literature include the modified frailty index, Groningen Frailty Indicator, and John Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Most studies demonstrated a significant association between frailty and perioperative outcomes, including mortality, perioperative complications, and Clavien-Dindo grade IV complications. Furthermore, frailty was associated with greater length of hospital stay, readmission rate, and likelihood of discharge to short-term or skilled nursing facilities. The current literature demonstrates the utility of frailty as a predictor of perioperative mortality and morbidity. Further research is needed to develop frailty screening measures in order to risk-stratify patients and optimize modifiable factors preoperatively. Laryngoscope, 130:1436-1442, 2020.

Predicting Short-term Outcomes After Radical Cystectomy Based on Frailty

ObjectiveTo evaluate the impact of frailty on adverse perioperative outcomes in patients treated with radical cystectomy for bladder cancer. Material and MethodsWe identified 9459 adults (age ≥18) in the Nationwide Readmission Database who underwent radical cystectomy in 2014 for bladder cancer. We defined patients’ frailty status using Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator and compared in-hospital mortality, ICU-level complications, 30-day readmissions, nonhome discharge, length of hospitalization, and hospital-related costs between frail and nonfrail patients using χ2 tests. We used multivariate logistic regression to identify predictors of the primary outcomes of interest. ResultsOf 9459 patients undergoing radical cystectomy, 7.1% (n = 673) met criteria. Frail patients were more likely than nonfrail patients to have comorbid conditions (68.2% vs 59.7%; P= .005), in-hospital mortality (4.2% vs 1.5%; P= .04), ICU-level complications (52.9% vs 18.6%; P<.001), nonhome discharge (33.9% vs 11.6%; P <.001), longer length of stay (median 15 vs 7 days; P<.001), and higher median cost of the index admission ($39,665 vs $27,307). Frailty was the strongest independent predictor of ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs of any covariate. ConclusionFrail patients receiving radical cystectomy were more likely than nonfrail patients to have adverse perioperative outcomes and higher odds of in-hospital mortality, ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs. Preoperative consideration of frailty may be useful in clinical guidance and shared decision-making.

The impact of frailty on perioperative outcomes and resource utilization in sinonasal cancer surgery.

Frailty is a measure of decreased physiologic reserve that has been associated with adverse outcomes in older surgical patients. We aimed to measure the association of preoperative frailty with outcomes in patients undergoing sinonasal cancer surgery. Retrospective cohort study. We identified 5,346 patients in the Nationwide Readmissions Database undergoing sinonasal cancer surgery from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multivariate regression was used to analyze the association of frailty with postoperative outcomes. Frailty was present in 7.4% of patients. Frailty was a significant independent predictor of intensive care unit-level complications (odds ratio [OR]: 4.83; 95% confidence interval [CI]: 2.95-7.93; P < .001) and nonhome discharge (OR: 3.07; 95% CI: 1.68-5.60; P < .001). Compared to nonfrail patients, frail patients had threefold longer median length of stay (12 days vs. 4 days; P < .001) and more than twofold higher median hospital costs ($44,408 vs. $18,660; P < .001). Frailty outperformed advanced comorbidity (defined as Charlson-Deyo score ≥3), age ≥80 years, and markers of surgical complexity (e.g., skull base/orbit involvement, flap reconstruction, neck dissection) in predicting serious complications, nonhome discharge, length of stay, and hospital costs. Frailty appears to have a stronger and more consistent association with adverse outcomes and increased resource utilization after sinonasal cancer surgery than age or comorbidity index. This information may be used in surgical risk stratification and can guide strategies to prevent or mitigate adverse events in this high-risk group. NA Laryngoscope, 130:290-296, 2020.