Frail Surgical Patients Research Articles

ThP6.4 - Psoas Sarcopaenia as a Predictor of Mortality in Patients Over 65 with PR Bleeding: A Retrospective Case Controlled Study

Abstract Aims Sarcopaenia has been examined as a predictor for functional baseline and frailty in surgical patients and may predict mortality. The hypothesis of this study is that sarcopaenia is associated with increased risk of death after per rectal (PR) bleeding. Methods Patients over 65 who were admitted between January 2017 and December 2022, having had an episode of PR bleeding, that underwent cross sectional imaging were identified from the Southern health and social care trust database. Cross sectional imaging was accessed via PACS and total psoas area (TPA) calculated at the third lumbar vertebra by a radiology trainee and validated by a consultant radiologist. Clinical, mortality and demographic data was obtained from Northern Ireland Electronic Care Record (NIECR). Psoas muscle index (PMI) was then calculated by TPA and standardising for height in mm2/m2. Sarcopaenia was defined as PMI male < 545 mm2/m2 female < 385 mm2/m2. Results 77 Patients were included in this study. Patients were excluded based on the ability to standardise TPA for height. 27% (n 21) of patients were identified as sarcopaenic, 66% (n 14) of these patients have died. The median PMI showed differences between female mortality (490.44 mm2/m2) and non-mortality (559.49 mm2/m2) groups. Male patients also showed lower median PMI between mortality (599.79 mm2/m2) and non-mortality (643.05 mm2/m2 ) groups. Conclusions Sarcopaenia as a predictor for frailty is an important risk factor for all-cause mortality in PR bleeding. Cross-sectional imaging provides an opportunity to quantify risk as well as investigate aetiology for PR bleeding. Although radiation risk and cost effectiveness may limit use, it should be considered when imaging is available.

Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review

BackgroundPreoperative frailty is associated with increased risk of adverse outcomes. In 2017, McIsaac and colleagues’ systematic review found that few interventions improved outcomes in this population and evidence was low-quality. We aimed to systematically review the evidence for multicomponent perioperative interventions in frail patients that has emerged since McIsaac et al.’s review.MethodsPUBMED, EMBASE, Cochrane, and CINAHL databases were searched for English-language studies published since January 1, 2016, that evaluated multicomponent perioperative interventions in patients identified as frail. Quality was assessed using the National Institute of Health Quality Assessment Tool. A narrative synthesis of the extracted data was conducted.ResultsOf 2835 articles screened, five studies were included, all of which were conducted in elective oncologic gastrointestinal surgical populations. Four hundred and thirteen patients were included across the five studies and the mean/median age ranged from 70.1 to 87.0 years. Multicomponent interventions were all applied in the preoperative period. Two studies also applied interventions postoperatively. All interventions addressed exercise and nutritional domains with variability in timing, delivery, and adherence. Multicomponent interventions were associated with reduced postoperative complications, functional deterioration, length of stay, and mortality. Four studies reported on patient-centred outcomes. The quality of evidence was fair.ConclusionsThis systematic review provides evidence that frail surgical patients undergoing elective oncologic gastrointestinal surgery may benefit from targeted multicomponent perioperative interventions. Yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care. Larger, low risk of bias studies are needed to evaluate optimal intervention delivery, effectiveness in other populations, implementation in health care settings and ascertain outcomes of importance for frail patients and their carers.

Automated CT Analysis of Body Composition as a Frailty Biomarker in Abdominal Surgery

Prior studies demonstrated consistent associations of low skeletal muscle mass assessed on surgical planning scans with postoperative morbidity and mortality. The increasing availability of imaging artificial intelligence enables development of more comprehensive imaging biomarkers to objectively phenotype frailty in surgical patients. To evaluate the associations of body composition scores derived from multiple skeletal muscle and adipose tissue measurements from automated segmentation of computed tomography (CT) with the Hospital Frailty Risk Score (HFRS) and adverse outcomes after abdominal surgery. This retrospective cohort study used CT imaging and electronic health record data from a random sample of adults who underwent abdominal surgery at 20 medical centers within Kaiser Permanente Northern California from January 1, 2010, to December 31, 2020. Data were analyzed from April 1, 2022, to December 1, 2023. Body composition derived from automated analysis of multislice abdominal CT scans. The primary outcome of the study was all-cause 30-day postdischarge readmission or postoperative mortality. The secondary outcome was 30-day postoperative morbidity among patients undergoing abdominal surgery who were sampled for reporting to the National Surgical Quality Improvement Program. The study included 48 444 adults; mean [SD] age at surgery was 61 (17) years, and 51% were female. Using principal component analysis, 3 body composition scores were derived: body size, muscle quantity and quality, and distribution of adiposity. Higher muscle quantity and quality scores were inversely correlated (r = -0.42; 95% CI, -0.43 to -0.41) with the HFRS and associated with a reduced risk of 30-day readmission or mortality (quartile 4 vs quartile 1: relative risk, 0.61; 95% CI, 0.56-0.67) and 30-day postoperative morbidity (quartile 4 vs quartile 1: relative risk, 0.59; 95% CI, 0.52-0.67), independent of sex, age, comorbidities, body mass index, procedure characteristics, and the HFRS. In contrast to the muscle score, scores for body size and greater subcutaneous and intermuscular vs visceral adiposity had inconsistent associations with postsurgical outcomes and were attenuated and only associated with 30-day postoperative morbidity after adjustment for the HFRS. In this study, higher muscle quantity and quality scores were correlated with frailty and associated with 30-day readmission and postoperative mortality and morbidity, whereas body size and adipose tissue distribution scores were not correlated with patient frailty and had inconsistent associations with surgical outcomes. The findings suggest that assessment of muscle quantity and quality on CT can provide an objective measure of patient frailty that would not otherwise be clinically apparent and that may complement existing risk stratification tools to identify patients at high risk of mortality, morbidity, and readmission.

Provider Perceptions Regarding Cardiopulmonary Resuscitation in Surgical Patients with Frailty.

To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty. The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of cardiopulmonary resuscitation (CPR) in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown. We performed qualitative thematic analysis of transcripts from semi-structured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at two academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients. We identified 5 themes: perceptions of perioperative CPR in patients with frailty vary by provider specialty; judgments regarding appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology; resuscitation in patients with frailty is sometimes associated with moral distress; biases such as ableism and ageism may skew clinicians' perceptions of appropriateness of perioperative CPR in patients with frailty; and evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate. Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases such as ageism and ableism.

OGC P23 Modified Frailty Index is not a good predictive tool of postoperative mortality following minimally invasive oesophagectomy

Abstract Background Evaluating frailty in the elderly population is crucial in preoperative assessment to identify high-risk patients. The modified frailty index (m-FI) is known to predict postoperative mortality in various surgical populations, but its predictive value in oesophagectomy patients' long-term mortality is unclear. No studies have specifically quantified frailty and its association with long-term postoperative mortality in oesophagectomy patients. This study investigates the association between m-FI score and long-term mortality in patients undergoing minimally invasive oesophagectomy (MIO). Methods The m-FI is a scoring tool of 11 parameters quantifies frailty in surgical patients. Retrospective analysis (1/1/2014-31/12/2023) of patients aged ≥75 years undergoing minimally invasive oesophagectomy procedures for cancer, at a single h[ka1] igh volume tertiary referral centre was carried out. Primary outcome was defined as 1-year all-cause mortality with overall length of survival as the secondary outcome. After sensitivity analyses m-fi score of less than 1 or greater than 2 were most predictive of mortality. Results Ninety-one patients (mean age 78 years, age range 75-88, male to female ratio of 4:1) were included, with a median m-FI score of 1 (range: 0-5). Patients with an m-FI score of ≥2 had a higher 1-year mortality rate (30% vs. 19%, p=0.195) and shorter overall median survival time (34 months vs. 47 months, p=0.399) compared to those with a score of ≤1. After adjusting for covariates, including preoperative chemotherapy, age, sex, and cancer staging, an m-FI score of ≥2 had a hazard ratio of 1.65 (95% CI: 0.68 to 3.98, p=0.267) for 1-year mortality compared to ≤1. Conclusions The m-FI tool can predict post operative mortality in a range of surgical specialities. The results of our study would suggest that higher m-FI score would correlate with worse long term mortality outcomes, however at this stage the m-FI tool cannot be applied in a clinical setting to accurately define elderly patient's probable outcome following MIO. Additional multicentre data is needed to establish its true predictive value in this patient cohort.

Frailty

Frailty in ageing surgical populations worldwide is one of the greatest global health challenges. Currently, 30% of Australian surgical patients are already aged>65 years, with 40,000–50,000 patients with frailty admitted to an Australian intensive care unit (ICU) annually. By 2030, 25% of Australian ICU bed-days will be occupied by patients aged>80 years. Major organisations such as the American Geriatrics Society and the American College of Surgeons strongly recommend perioperative frailty measurement, with clear evidence that this leads to reduced mortality. However, widespread routine systems to measure frailty in surgical patients are lacking. This is despite clear evidence of significantly increased postoperative mortality, new disability, and residential care placement after surgery with frailty.

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Delirium Prevention and Management in Frail Surgical Patients.

Delirium, an acute, fluctuating impairment in cognition and awareness, is one of the most common causes of postoperative brain dysfunction. It is associated with increased hospital length of stay, health care costs, and mortality. There is no FDA-approved treatment of delirium, and management relies on symptomatic control. Several preventative techniques have been proposed, including the choice of anesthetic agent, preoperative testing, and intraoperative monitoring. Frailty, a state of increased vulnerability to adverse events, is an independent and potentially modifiable risk factor for the development of delirium. Diligent preoperative screening techniques and implementation of prevention strategies could help improve outcomes in high-risk patients.

Preoperative frailty to predict short-term outcomes in patients with cancer.

810 Background: Frailty is associated with increased postoperative complications. Despite multiple evidence-based modalities to assess frailty, surgeons often make subjective assessments of patients’ ability to tolerate surgery. Identification of those at risk of poor outcomes is particularly important in Surgical Oncology, as major resections may worsen debility and functional status, limiting the patients' ability to receive further therapy. The Risk Analysis Index (RAI-C) is a validated tool to assess frailty in surgical patients. It assigns points for any cancer diagnosis, potentially overestimating frailty in Surgical Oncology patients, and has not been validated in this subgroup. Methods: We performed a prospective, surgeon-blinded study to correlate results of a preoperatively administered frailty survey to predict short- and long-term outcomes in patients with histologically proven malignancy who underwent surgery. The RAI-C, Patient Health Questionnaire (PHQ9), and General Anxiety Disorder (GAD) surveys were administered to assess for frailty, depression, and anxiety, respectively; C-reactive protein (CRP), pre-albumin, albumin, and hematocrit were obtained. Outcomes, including readmission, major complications, ICU admission, disposition (home vs rehabilitation/nursing facility), and 1-year survival were compared between the different groups as defined by survey and lab results. Results: One hundred ninety-one patients were included, of which 135 patients were considered frail based on the predefined value (RAI-C ≥21). Frail patients were more likely to be readmitted within 30 days (14% vs 2%, P=0.01). No difference was found in length of stay, 90-day readmission, ICU admission, major complications, or disposition. Only 15.8% of patients met criteria for anxiety and 11% met criteria for depression. Measured outcomes were similar in patients defined as anxious or depressed. Patients with abnormal pre-albumin levels were more likely to require ICU admissions (31% vs 8%, P &lt;0.005), postoperative intubation (12% vs 0.02%, P=0.02), and to be discharged to a facility other than home (19% vs 10%, P=0.01). Similar trends were noted for patients with abnormal albumin levels who also had longer lengths of stay (mean 9.32 vs 7.88 days, P=0.007). There was an association of improved 1-year survival in patients with normal CRP, pre-albumin, albumin, and hematocrit levels. Frailty as determined by RAI-C survey was not associated with decreased 1-year survival. Conclusions: The RAI-C is a validated tool that can be used for prescreening of Surgical Oncology patients at risk of postoperative readmission, however the score did not correlate with other important outcomes including major morbidity, discharge disposition, and 1-year survival. Results from the survey, as well as preoperative laboratory results can be used in screening patients who may benefit from preoperative optimization and increased follow-up.

Reviewing next of kin regrets in surgical decision-making: cross-sectional analysis of systematically searched literature

BackgroundDecision-making concerning relatives undergoing surgery is challenging. It remains unclear to what extent implicated next of kin eventually regret their decisions and how this regret is assessed. Our aim was to systematically review the literature on decisional regret of next of kin and to describe the assessment tools used and the surgical populations studied.MethodsWe included interventional or observational, quantitative or qualitative studies reporting the measurement of decisional regret of next of kin concerning relatives undergoing surgery. We searched a variety of databases without restriction on publication year. We assessed the quality of reporting of quantitative studies using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and of qualitative studies using the Critical Appraisal Skills Program Checklist.ResultsThirteen cross-sectional, five prospective cohorts and five qualitative studies matched our inclusion criteria. In 18 studies (78%), patients were children, in five (22%), young or middle-aged adults. No study included elderly or frail patients. Thirteen studies (57%) used the original Decision Regret Scale which was validated for patients, but not for next of kin. Only 3 of the 18 (17%) quantitative studies and only one of the 4 (25%) qualitative studies were rated as “good” in the quality assessment.ConclusionNone of the retrieved studies used validated tools to assess the decisional regret of next of kin and none of them examined this issue in elderly or frail surgical patients.

ALIGN-CARE: IMPLEMENTATION AND FEASIBILITY OF NEW GERIATRIC SURGERY CO-MANAGEMENT MODEL FOR PHYSICAL AND SOCIAL FRAILTY

Abstract Pre-operative geriatric evaluation in frail older patients that addresses both medical and psychosocial needs is often not completed prior to surgery, leaving frail older adults ill prepared for surgery. The ALIGN-CARE interprofessional co-management model uniquely serves to standardize care and coordination amongst the surgeon, geriatrician and social worker in ambulatory settings to allow a greater window of time to intervene for surgical optimization. Program elements include assessment of preoperative medications, functional status, cognition, nutrition, What Matters Most, advance care planning (ACP), and social determinants of health. Recommendations and action items from the geriatric-social work team are presented to surgeon and primary care physicians for follow-up and optimization. Program and process elements recorded in a REDCap database facilitate longitudinal evaluation of ALIGN-CARE model implementation feasibility. Initial data of 9 frail surgical oncology patients indicate increases in meaningful ACP discussions, patient-oriented decisions regarding surgery candidacy, and surgeon referrals for inpatient geriatric consultation post-operatively as a result of ALIGN-CARE. Current analyses to assess feasibility and quality of the program include thematic coding of program documents, semi-structured interviews of key stakeholders (surgeons, geriatricians, social workers, patients), and quantitative analysis of program outcomes, including uptake of program elements and process measures. Planned areas of analytic focus include workflow, cross-specialty coordination, and patient and primary care engagement and activation. We anticipate identifying specific barriers and facilitators of ALIGN-CARE implementation in our evaluation to aid the dissemination and upscaling of interprofessional co-management programs aimed to improve outcomes and quality of life for frail, older surgical patients.

Potentially Inappropriate Medication Administration Is Associated With Adverse Postoperative Outcomes in Older Surgical Patients: A Retrospective Cohort Study.

The American Geriatrics Society (AGS) Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) best avoided in adults ≥65 years of age. Cognitively impaired and frail surgical patients often experience poor outcomes after surgery, but the impacts of PIMs on these patients are unclear. Our objective was to assess whether perioperative PIM administration was associated with poor outcomes in geriatric surgical patients. We then evaluated the association between PIM administration and postoperative outcomes in subgroups of patients who were frail or cognitively impaired. We performed a retrospective cohort study of patients ≥65 years of age who underwent elective inpatient surgery at a large academic medical center from February 2018 to January 2020. Edmonton Frail Scale and Mini-Cog screening tools were administered to all patients at their preoperative clinic visit. A Mini-Cog score of 0 to 2 was considered cognitive impairment, and frailty was defined by an Edmonton Frail Scale score of ≥8. Patients were divided into 2 groups depending on whether they received at least 1 PIM (PIM+), based on the 2019 AGS Beers Criteria, in the perioperative period or none (PIM-). We assessed the association of preoperative frailty, cognitive impairment, and perioperative PIM administration with the length of hospital stay and discharge disposition using multiple regression analyses adjusted for age, sex, ASA physical status, and intensive care unit (ICU) admission. Of the 1627 included patients (mean age, 73.7 years), 69.3% (n = 1128) received at least 1 PIM. A total of 12.7% of patients were frail, and 11.1% of patients were cognitively impaired; 64% of the frail patients and 58% of the cognitively impaired patients received at least 1 PIM. Perioperative PIM administration was associated with longer hospital stay after surgery (PIM-, 3.56 ± 5.2 vs PIM+, 4.93 ± 5.66 days; P < .001; 95% confidence interval [CI], 0.360-0.546). Frail patients who received PIMs had an average length of stay (LOS) that was nearly 2 days longer than frail patients who did not receive PIMs (PIM-, 4.48 ± 5.04 vs PIM+, 6.33 ± 5.89 days; P = .02). Multiple regression analysis revealed no significant association between PIM administration and proportion of patients discharged to a care facility (PIM+, 26.3% vs PIM-, 28.7%; P = .87; 95% CI, -0.046 to 0.054). Perioperative PIM administration was common in older surgical patients, including cognitively impaired and frail patients. PIM administration was associated with an increased hospital LOS, particularly in frail patients. There was no association found between PIM administration and discharge disposition.

Decision making in frail patients at risk of postoperative delirium: A case study and literature review

Preoperative frailty is strongly associated with risks of postoperative delirium. However, gaps exist in targeted recommendations for clinical decision making related to surgical interventions in frail older patients. A case study is presented involving a frail 74-year-old referred to the palliative care team for assistance with clinical decision making and in weighing risks and benefits of a surgical intervention. A literature review on the quantification of postoperative delirium risk and how this information might inform medical decision making in frail surgical patients did not identify clear clinical guidelines. In the absence of practice guidelines, the Patient Priorities Care model is proposed as a framework to help providers working with patients and caregivers facing complex medical decisions to better align interventions with patient values.

Frailty index is useful for predicting postoperative morbidity in older patients undergoing gastrointestinal surgery: a prospective cohort study

BackgroundMany assessment tools have been used to identify frail surgical patients. This study was designed to explore the prediction value of the frailty index (FI) for postoperative morbidity in older patients undergoing elective gastrointestinal surgery.MethodsBetween January 2019 and September 2020, we conducted a prospective study in our hospital, and patients aged over 65 years were enrolled. The FI assessment was conducted by two specialist nurses based on the 38-item scale, and patients were considered frail if the FI score was ≥ 0.25. The primary outcome was 30-day postoperative morbidity. Univariable and multivariable analyses were used to find the risk factors related to postoperative morbidity.ResultsA total of 246 consecutive patients were enrolled, for whom the median age was 72.0 [interquartile range (IQR): 67.0–77.0] years old, and 175 (71.1%) were male. Of these, 47 (19.1%) were frail. Patients with frailty were associated with older age (p < 0.001), higher American Society of Anesthesiologists (ASA) grade (p = 0.006), lower body mass index (p = 0.001), lower albumin (p = 0.003) and haemoglobin (p < 0.001) levels, increased blood loss (p = 0.034), increased risk of postoperative morbidity (p < 0.001), increased median length of stay (p = 0.017), and increased median postoperative hospital stay (p = 0.003). Multivariable analysis revealed that ASA grade [odds ratio (OR): 2.59, 95% confidence interval (CI) 1.19–5.64, p = 0.016], FI score (OR 7.68, 95% CI 3.19–18.48, p < 0.001) and surgical complexity (OR 22.83, 95% CI 5.46–95.51, p < 0.001) were independent predictors of 30-day postoperative morbidity. However, for patients with major surgery, FI score was the only independent predictor (OR 8.67, 95% CI 3.23–23.25, p < 0.001).ConclusionFrailty was associated with adverse perioperative outcomes, and the 38-item FI scale was a useful frailty screening tool for older patients undergoing elective gastrointestinal surgery. For patients with major surgery, frailty was a more reliable predictor of postoperative 30-day morbidity than age and ASA grade.

Frailty in Surgical Patients: Is it Relevant to Sexual Medicine?

BackgroundAs the age of our surgical population continues to rise, there is an increased need for adequate preoperative evaluation and risk stratification to ensure the best possible surgical outcomes for patients. AimWe sought to describe the 3 main models currently used to evaluate patient frailty and explore how they are being utilized in the field of surgery and sexual medicine. MethodsWe reviewed online resources including Pubmed with relevant search criteria centered around frailty, surgery, sexual medicine, and prosthetics. Outcomes/ResultsAll relevant studies were reviewed and several models for patient frailty emerged; the Phenotype Model, the Frailty Index, the Clinical Frailty Scale, and the modified Frailty Index. Worse frailty indices were seen to be linked to higher rates of complications and mortalities postoperatively. Clinical ImplicationsAlthough the adoption of patient frailty in the field of sexual medicine has been sluggish, few studies have shown that its use could help predict which patients are at increased risk of complications and may require more support when it comes to postoperative care and teaching. Strength & LimitationsOverall there is a paucity of literature as it relates to sexual medicine and patient frailty and this paper provides a limited look at the usage of patient frailty in sexual medicine. ConclusionWe implore all sexual health providers to begin to incorporate frailty metrics when caring for this population to help reduce postoperative complications and help better predict surgical success.Burns RT and Bernie HL, Frailty in Surgical Patients: Is it Relevant to Sexual Medicine?. J Sex Med 2022;19:401–403.

Low free testosterone is associated with increased mortality in frail surgical patients

BackgroundPreoperative frailty has been associated with adverse postoperative outcomes. Additionally, low testosterone has been associated with physical frailty and cognitive decline. However, the impact of simultaneous frailty and low testosterone on surgical outcomes is understudied. MethodsPreoperative frailty status and testosterone levels were obtained in patients undergoing a diverse range of surgical procedures. Preoperative frailty was evaluated independently and in combination with testosterone through the creation of composite risk groups. Relationships between preoperative frailty and composite risk groups with overall survival were determined using Kaplan–Meier and logistic regression analyses. Bivariate analysis was used to determine the associations between frailty and testosterone status on postoperative complications, length of hospital stay, and readmission rates. ResultsMedian age of the cohort was 63 years, and the median follow-up time was 105 weeks. Thirty-one patients (23%) were frail, and 36 (27%) had low free testosterone. Bivariate analysis demonstrated a statistically significant relationship between preoperative frailty and overall survival (P = .044). In multivariate analysis, coexisting frailty and low free testosterone were significantly associated with decreased overall survival (hazard ratio 4.93, 95% confidence interval, 1.68–14.46, P = .004). ConclusionWe observed preoperative frailty, both independently and in combination with low free testosterone levels, to be significantly associated with decreased overall survival across various surgical procedures. Personalizing the surgical risk assessment through the incorporation of preoperative frailty and testosterone status may serve to improve the prognostication of patients undergoing major surgery.

Are trainees working in obstetrics and gynecology confident and competent in the care of frail gynecological oncology patients?

IntroductionOlder patients undergoing cancer surgery are at increased risk of post-operative complications, prolonged hospital stay, and mortality. Identification of frailty can help predict patients at high risk of peri-operative complications...

127. Preoperative optimization of modifiable frailty factors reduces risk of hospital acquired conditions in elective surgical spine patients

BACKGROUND CONTEXT Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores. METHODS Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] 0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between ‘optimized’ and ‘non-optimized’ frailty status in the cohort. Level of significance was set to P RESULTS A total of 196,523 patients (57±14.2 years, 30.4 kg/m2, 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p CONCLUSIONS Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Prehabilitation in Frail Surgical Patients: A Systematic Review.

Frailty is a customized marker of biological age that helps to gauge an individual's functional physiologic reserve and ability to react to stress and is associated with increased postoperative morbidity and mortality. In order to mitigate frailty preoperatively, the concept of prehabilitation has entered the forefront which encompasses multidisciplinary interventions to improve health and lessen the incidence of postoperative decline. The purpose of this study is to investigate the impact of prehabilitation on postoperative outcomes in frail, surgical patients. A comprehensive literature search was performed by two independent researchers according to PRISMA guidelines. Inclusion criteria were (1) a randomized controlled trial, case-control or observational study; (2) prehabilitation intervention; (3) frailty assessment; and (4) surgical intervention. There were five articles included in the review. Evaluation of these articles demonstrated prehabilitation may improve operative outcomes in frail surgical patients. There were no assessments as to whether prehabilitation was cost-effective although it was feasible. Prehabilitation programs should include elements of exercise, nutrition, and psychosocial counseling. Frailty should be assessed with a validated index in surgical patients who may undergo prehabilitation. Prehabilitation in frail surgical patients may be the appropriate process through which providers can lessen operative risk. Currently, however, there is little evidence supporting the use of prehabilitation in this population with only five studies identified in this systematic review. More randomized controlled trials are clearly needed.

Age, Not Sex, Modifies the Effect of Frailty on Long-term Outcomes After Cardiac Surgery.

To examine the prevalence of frailty in surgical patients and determine whether age and sex modify the relationship between frailty and long-term mortality. Frailty is a complex and prevalent clinical syndrome. The cardiac surgery literature consists mostly of small, single-center studies, and the epidemiology of frailty remains to be fully elucidated in a real-world surgical population. This retrospective cohort study included patients who underwent coronary artery bypass grafting, and/or aortic, mitral or tricuspid valve surgery in Ontario, Canada, between 2008 and 2016. The primary outcome was all-cause mortality. Survival probabilities were calculated using the Kaplan-Meier method, and the association of covariates with the hazard of death was assessed using multivariable Cox proportional hazard models. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Of 72,824 patients, 11,685 (16%) were frail. At median 5 ± 2 years of follow-up, 2921 (25.0%) frail patients and 8637 (14.1%) non-frail patients had died [adjusted hazard ratio 1.60; 95% confidence interval (CI), 1.53-1.68]. The adjusted hazard ratio was highest in patients who underwent isolated mitral (2.18; 95% CI, 1.71-2.77) and mitral + aortic valve surgery (1.85; 95% CI, 1.33-2.58) and lowest after coronary artery bypass grafting + mitral valve surgery (1.38; 95% CI, 1.11-1.70). Age, but not sex, modified the effect of frailty on mortality; such that the rate of death decreased linearly with increasing patient age. We observed a high prevalence of frailty in patients undergoing cardiac surgery, and a statistically significant association between frailty and long-term mortality after cardiac procedures. Importantly, the rate of death was inversely proportional to age, such that frailty had a stronger adverse impact on younger patients. Our findings highlight the need to incorporate frailty into the preoperative risk stratification and investigate strategies to support younger patients who are frail.