Modified Frailty Index Research Articles

(033) Analyzing Patient-Specific Predictors of Surgical Risk and Outcomes Following Gender-Affirming Surgery

Abstract Introduction Gender affirming surgery (GAS) has seen dramatic advances in phalloplasty and vaginoplasty for gender dysphoria. However, there is still need for better characterization of patient demographics and surgical outcomes. Recent interest has emerged in predictors of post-surgical complications, such as patient frailty and comorbidities for preoperative risk assessment. Better understanding factors predicting outcomes can help with patient selection, patient counseling, and quality improvement. Objective To evaluate phalloplasty and vaginoplasty outcomes and predictors of complications utilizing the National Surgical Quality Improvement Program (NSQIP) database. Methods CPT codes were utilized to identify phalloplasty (59980) and vaginoplasty (59970, 57335) cases recorded in NSQIP from 2006-2020. Descriptive statistics were calculated for baseline patient characteristics, operative parameters, and 30-day complications. Frailty was calculated using the modified frailty index (NSQIP-mFI-5), a previously validated 5-item score including points for diabetes, impaired functional status, COPD, CHF, and hypertension. Pre-operative morbidity probabilities were derived from the “MORBPROB” variable, which is the NSQIP morbidity probability, which uses hierarchical regression analysis on patient-specific factors. Univariate logistic regression, ANOVA, and t-test analyses were performed as appropriate to identify predictors of surgical complications, operative time, and hospital length of stay (LOS). Results Out of 9,637,305 patients in the NSQIP database, 58 underwent phalloplasty and 485 underwent vaginoplasty. For phalloplasty and vaginoplasty, the mean patient age was 38.4±11.8 and 36.6±12.6 years, respectively. The average operative time for phalloplasty and vaginoplasty was 331 minutes and 263 minutes respectively, and the average LOS was 5.1 days and 4.3 days, respectively. The overall 30-day complication rate for phalloplasty was 26%, with 17% of all patients experiencing minor complications, including urinary tract infections, superficial wound infections, pneumonia, and peri-operative bleeding requiring transfusion, and 16% of all patients experiencing major complications including occurrences of sepsis, DVT, stroke, reintubation, renal failure, myocardial infarction, pulmonary embolism, septic shock, would dehiscence, deep wound infections, and cardiac arrest. The overall, minor, and major complications rates for vaginoplasties were 14%, 7%, and 9%. Unplanned readmissions and reoperations each occurred in 7% phalloplasty and 5% vaginoplasty patients. In either cohort, no deaths occurred within 30 days post-operation. Upon logistic regression, NSQIP-mFI-5 scores ≥0.2 versus a score of 0 were not predictive of 30-day complications, operative time, or LOS for either procedure. Notably, for vaginoplasties, higher NSQIP-mFI-5 scores were numerically associated with higher complication rates (OR 2.02, 95% CI 0.94-4.09, p=0.072). When comparing NSQIP preoperative morbidity probabilities of ≥10% versus <10%, this score was predictive of 30-day complications for both phalloplasty (OR 4.0, 95% CI 1.1-19.6, p=0.038) and vaginoplasty (OR 2.46, 95% CI 1.4-4.3, p<0.001). NSQIP morbidity probability ≥10% was also predictive of extended LOS for phalloplasty patients (6.3±1.3 vs. 2.9±0.8, p=0.03). Conclusions This study described the complication rates of phalloplasty and vaginoplasty using the NSQIP database which are largely aligned with previously published studies. The NSQIP preoperative morbidity probability is an effective predictor of surgical complications and is a better predictor than the modified NSQIP frailty index. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Paul Chung - Consultant for Boston Scientific and Coloplast.

(431) Frailty Does Not Predict Postoperative Complications Following Inflatable Penile Prosthesis Surgery

Abstract Introduction Frailty, an approximation of a patient’s reserve resulting from age-associated decline across multi-organ systems, has been shown to be an independent predictor of adverse outcomes. Amongst penile prosthesis surgery however, frailty is an underutilized risk factor with conflicting data regarding its impact on surgical outcomes. Objective To evaluate the association between the modified Frailty Index (mFI) and adverse outcomes following inflatable penile prosthesis (IPP) surgery. Methods A retrospective chart review of men who underwent IPP surgery between 1/1/13 and 7/31/20 at a single-institution was conducted. Patient frailty was defined using the mFI, a previously validated measure, which consists of 11 patient characteristics. Each variable is allotted 1 point with aggregate scores ranging from 0 (no frailty) to 11 (highest degree of frailty). Complications were defined as mechanical failure, erosion, infection, hematoma, intractable pain, or other (ex. herniated reservoir, pump revision). Logistic regression was used to determine the association between mFI and complications after controlling for predetermined covariates. Results The final cohort consisted of 337 IPP patients with a median age of 64.6 years (IQR 58.5-68.4) and a median time from surgery to data collection of 66.6 months (IQR 39.0-85.4). The overall complication rate was 9.8% (n=33) with 63.6% of those (n=21) requiring a surgical intervention (ex. explant, remove/replace, revision). The median mFI for patients with a complication was 2 (IQR 1-3) while the median mFI for those without a complication was 1 (IQR 1-2) (Table 1). When adjusting for confounding variables on multivariable analysis, mFI was not associated with either overall (p=0.20) or operative complications (p=0.69) (Table 2). Conclusions While specific frailty metrics such as handgrip strength have been shown to be associated with complications following IPP placement, our results suggest that overall mFI was not associated with adverse outcomes following IPP surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

Is Frailty a Good Predictor of Postoperative Complications in Elective Abdominal Surgery?-A Single-Center, Prospective, Observational Study.

Despite the common occurrence of postoperative complications in patients with frailty syndrome, the nature and severity of this relationship remains unclear. We aimed to assess the association of frailty with possible postoperative complications after elective, abdominal surgery in participants of a single-centre prospective study in relation to other risk classification methods. Frailty was assessed preoperatively using the Edmonton Frail Scale (EFS), Modified Frailty Index (mFI) and Clinical Frailty Scale (CFS). Perioperative risk was assessed using the American Society of Anesthesiology Physical Status (ASA PS), Operative Severity Score (OSS) and Surgical Mortality Probability Model (S-MPM). The frailty scores failed to predict in-hospital complications. The values of AUCs for in-hospital complications ranged between 0.5 and 0.6 and were statistically nonsignificant. The perioperative risk measuring system performance in ROC analysis was satisfactory with AUC ranging from 0.63 for OSS to 0.65 for S-MPM (p < 0.05 for each). The analysed frailty rating scales proved to be poor predictors of postoperative complications in the studied population. Scales assessing perioperative risk performed better. Further studies are needed to obtain optimal predictive tools in senior patients undergoing surgery.

SP28. The Risk Analysis Index Has Superior Frailty Discrimination Than the Modified Frailty Index-5 for Predicting Poor Cranioplasty Outcomes

PURPOSE: Cranioplasty is a common surgical procedure where autologous or synthetic materials are used to repair cranial defects and although considered simple and low-risk, it is surprisingly associated with significant morbidity and mortality. Although increased patient age has been shown to be a predictor of poor postoperative outcomes, no studies have evaluated frailty’s impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing effect sizes of the Risk Analysis Index-Administrative (RAI-A), Modified Frailty Index-5 (mFI-5), and increasing patient age on the primary outcome of 30-day mortality and secondary outcomes of non-home discharge rates and postoperative complications, as measured by the Clavien-Dindo (CD) complication classification system: (CD I: surgical site infection, CD II: postoperative bleeding or transfusion(s), CD IIIb: reoperation under general anesthesia, CD IV: sepsis, septic shock, pulmonary embolism, myocardial infraction, ventilator status, 30-day mortality). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for all patients undergoing cranioplasty between 2012-2020. Data for baseline demographics, comorbidities, operative characteristics, and postoperative outcomes were evaluated. Statistical analysis was performed on IBM SPSS Statistics ver. 28.0 (IBM Co., Armonk, NY, USA). The discriminatory thresholds of RAI-A, mFI-5, and increasing patient age on 30-day mortality were evaluated using receiver operating characteristics (ROC) curve analysis. The area under the curve (AUC) is represented as a C-statistic with a 95% confidence interval (CI). Two distinct multivariable analyses were conducted for RAI-A and mFI-5 to measure the independent relationships between frailty and outcomes. Covariates controlled for included race, BMI, primary procedure, cranial defect size, and material type. Additionally, the mFI-5 model was age-adjusted, allowing for direct comparison of effect sizes between age and frailty. We excluded age from the model for RAI-A to prevent any collinearity, since age contributes to the total RAI-A score. RESULTS: There were 2,864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were female (57.0%), and white (68.5%). The RAI-A demonstrated better predictive ability for 30-day mortality (C-Statistic: 0.741, 95% CI: 0.678-0.804) compared to mFI-5 (C-Statistic: 0.574, 95% CI: 0.489-0.659) and increasing patient age (C-Statistic: 0.671, 95% CI: 0.610-0.732). On multivariable analyses, RAI-A demonstrated superior independent associations with mortality, NHD, CDII, and CDIII when compared to mFI-5 and increasing patient age. (p<0.05). CONCLUSIONS: The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting poor outcomes following cranioplasty. The high rates of operative morbidity (5.0-36.5%) and mortality (0.4-3.2%) after cranioplasty highlight the importance of being able to predict which patients are at increased risk for poor cranioplasty outcomes, so that shared decision making regarding the potential risk and benefits of treatment can occur. Multivariable Analyses for Postoperative Outcomes

114. A Nationally Validated Novel Risk Assessment Score for Prediction of Unplanned Reoperations and Readmissions in Hand Surgery

PURPOSE: Risk predictors are an emerging tool as the need for granular, individualized risk estimation remains necessary for informed patient counseling and clinical decision making. Existing comorbidity-driven risk indices have had varied success in accurately predicting risk in hand surgery. This study provides a novel risk score for reliably predicting reoperations and readmissions in hand surgery. METHODS: Hand surgeries from the National Surgical Quality Improvement Program (NSQIP) 2012 to 2020 database were identified by Current Procedural Terminology (CPT) codes. Independent predictors of 30-day unplanned reoperation and readmission were identified using multivariable logistic regression with backward variable selection on the testing sample (2012-2019). Subsequently, the predictors were weighted according to β-coefficients to generate an integer-based Novel Risk Score (NRS) predictive of reoperation and readmission. The NRS was then validated on 1000 bootstrapped replications of the original sample, and again tested on NSQIP patients who had undergone hand surgery in 2020. The NRS was compared to the modified frailty index (mFI-5) and the modified Charlson Comorbidity Index (mCCI) with receiver operating characteristics (ROC) analysis. RESULTS: 83,409 hand surgeries were identified in the modeling cohort. Reoperations and readmissions occurred 1.1% and 1.3% of the time, respectively. Independent risk factors included male gender, inpatient status, smoking, dialysis dependence, transfusion within 72 hours of surgery, wound classification, ASA Class, diabetes mellitus, CHF, sepsis or septic shock, emergent case, and long initial operative time (all P < 0.05). ROC analysis of the testing (2020) cohort rendered an area under the curve of 0.730, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.580 and 0.585, respectively. CONCLUSION: We present a validated risk stratification tool for unplanned reoperations and readmissions following hand surgery that outperforms the mFI-5 and mCCI. Future studies should determine if implementation of this NRS optimizes safety and reduces reoperation and readmission rates in hand surgery patients.

Preoperative Frailty Predicts Worse Outcomes after Microvascular Decompression for Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: A Multicenter Analysis of 1,473 Patients from a Prospective Surgical Registry

Introduction: Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (n = 1,211), hemifacial spasm (n = 236), or glossopharyngeal neuralgia (n = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis. Results: Patients undergoing MVD (N = 1,473) were stratified by RAI frailty bins: 71% with RAI 0–20, 28% with RAI 21–30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, p = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, p = 0.001), and AD (6.1% vs. 1.0%, p < 0.001). The rate of primary endpoint was 2.4% (N = 36) and was positively associated with increasing frailty tier: 1.5% in 0–20, 5.8% in 21–30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74–0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61–0.66) (DeLong pairwise test, p = 0.003). Conclusions: This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression.

A Prospective Evaluation of Different Frailty Indices in Patients Undergoing Transurethral Resection of Bladder Tumor

BackgroundMost studies investigating the relationship between preoperative frailty and postoperative outcomes among bladder cancer patients only assess frailty retrospectively in patients who have undergone radical cystectomy. Transurethral resection of bladder tumor (TURBT) is a commonly performed procedure in outpatient settings for a large number of bladder cancer patients. The prevalence of frailty among bladder cancer patients and its impact on postoperative complications and mortality are not well studied. MethodsTo assess the prevalence of frailty among bladder cancer patients planned for TURBT at a tertiary cancer center using the modified frailty index (mFI) and Risk Analysis Index (RAI) and further assess the impact of these indices on 30-day postoperative complications and mortality rates. ResultsBetween May 2020 and March 2021, 343 consecutive patients were enrolled. The mean age of the cohort was 64.8 ± 13.1 years, 86.6% were male, and 82% had non–muscle-invasive bladder cancer (NMIBC). The majority of the cohort (92%) was found to have low American Society of Anesthesiologists (ASA) score class (I + II), while 35.3% were labeled as frail using mFI 2+, and 32.1% based on RAI (III, IV). The 30-day readmission, postoperative complications, and mortality rates in this cohort were 3.8%, 2.3%, and 6.6%, respectively. RAI was a better indicator of mortality compared to mFI. As such, patients with low RAI score (I, II) had 0.054 odds for 30-day mortality compared to the patients with high RAI score (III, IV) (OR 0.054; CI 95%, 0.004 to 0.784; P = 0.033).Conclusion Frailty, as measured by Risk Analysis Index, is an independent predictor of early mortality in patients undergoing TURBT. Preoperative frailty assessment may improve risk stratification and patient counseling prior to surgery.

Assessment of the incremental prognostic value from the modified frailty index-5 in complete traumatic cervical spinal cord injury

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [− 8.72 × 10–4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.

Five-Factor Modified Frailty Index as a Predictor of Complications Following Total Ankle Arthroplasty.

Ankle arthritis adversely affects patients' function and quality of life. Treatment options for end-stage ankle arthritis include total ankle arthroplasty (TAA). A 5-item modified frailty index (mFI-5) has predicted adverse outcomes following multiple orthopaedic procedures; this study evaluated its suitability as a risk-stratification tool in patients undergoing TAA. The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for patients undergoing TAA between 2011 and 2017. Bivariate and multivariate statistical analyses were performed to investigate frailty as a possible predictor of postoperative complications. In total, 1035 patients were identified. When comparing patients with an mFI-5 score of 0 versus ≥2, overall complication rates significantly increased from 5.24% to 19.38%, 30-day readmission rate increased from 0.24% to 3.1%, adverse discharge rate increased from 3.81% to 15.5%, and wound complications increased from 0.24% to 1.55%. After multivariate analysis, mFI-5 score remained significantly associated with patients' risk of developing any complication (P = .03) and 30-day readmission rate (P = .005). Frailty is associated with adverse outcomes following TAA. The mFI-5 can help identify patients who are at an elevated risk of sustaining a complication, allowing for improved decision-making and perioperative care when considering TAA. III, Prognostic.

Predictors of Adverse Outcomes and Mortality After Open Surgical Repair of Proximal Abdominal Aortic Aneurysms: the Five Factor Modified Frailty Index (mFI-5) Role

Objective: “Frailty” is defined as “a multidimensional syndrome of decreased reserve and resistance to stressors” and it has been associated with adverse outcomes in several fields of surgery. The aim of the study was to evaluate the correlation between frailty, measured by the Five Factor Modified Frailty Index (mFI-5) and all major adverse events (MAE), 30 day and midterm mortality in patients who underwent proximal abdominal aortic aneurysm (p-AAA) open surgery (OS).

The Role of Frailty and Sarcopenia in Predicting Major Adverse Events, Length of Stay and Reoperation Following En Bloc Resection of Primary Tumours of the Spine.

Retrospective observational cohort study. En bloc resection for primary tumours of the spine is associated with a high rate of adverse events (AEs). The objective was to explore the relationship between frailty/sarcopenia and major perioperative AEs, length of stay (LOS), and unplanned reoperation following en bloc resection of primary spinal tumours. This is a unicentre study consisting of adult patients undergoing en bloc resection for a primary spine tumor. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia was quantified with the total psoas area/vertebral body area ratio (TPA/VB) at L3 and L4. Univariable regression analysis was used to quantify the association between frailty/sarcopenia and major perioperative AEs, LOS and unplanned reoperation. 95 patients met the inclusion criteria. The mFI and STFI identified a frailty prevalence of 3% and 18%. Mean CT TPA/VB ratios were 1.47 (SD ± .05) and 1.83 (SD ± .06) at L3 and L4. Inter-observer reliability was .93 and .99 for CT and MRI L3 and L4 TPA/VB ratios. Unadjusted analysis demonstrated sarcopenia and mFI did not predict perioperative AEs, LOS or unplanned reoperation. Frailty defined by an STFI score ≥2 predicted unplanned reoperation for surgical site infection (SSI) (P < .05). The STFI was only associated with unplanned reoperation for SSI on unadjusted analysis, while the mFI and sarcopenia were not predictive of any outcome. Further studies are needed to investigate the relationship between frailty, sarcopenia and perioperative outcomes following en bloc resection of primary spinal tumors.

The 5-Factor Modified Frailty Index Score Predicts Return to the Operating Room for Patients Undergoing Posterior Spinal Fusion for Traumatic Spine Injury

Within the trauma spine surgery literature, the effect of patient frailty on postoperative outcomes for posterior spinal fusion (PSF) remains clear. In this study, the authors quantified the influence of the mFI-5 score on hospital length of stay (LOS), diagnosis of a postoperative infection, 30-day readmission and 90-day return to OR. The authors retrospectively reviewed the records of all patients with traumatic spine injury undergoing PSF by a single surgeon at our institution from 2016 to 2021. Data was extracted using manual chart review and the mFI-5 score was calculated using data on comorbidities. Bivariate (Mann-Whitney U-test and Fisher's exact test) and multivariate regressions (linear and logistic) revealed whether there was an independent relationship between patient frailty and postoperative outcomes. The patient cohort included 263 patients (52.00 ± 19.04), 67 (25.5) were classified as frail, defined as having an mFI-5 sore greater than or equal to 2. Patients who were classified as frail were significantly more likely to have diabetes (OR = 21.53, p<0.001) and active cancer (OR = 10.03, p = 0.004). Patients with mFI-5 scores greater than or equal to 2 were also significantly older (p<0.001) and had higher BMIs (p=0.007) Patients with mFI-5 scores greater than 2 were more likely to return to the OR (OR = 2.43, p=0.037) on bivariate analysis. When controlling for demographics and clinical characteristics, mFI-5 score independently predicted return to OR (OR = 1.294, p-value = 0.041). Patient frailty independently predicted a return to OR in patients undergoing PSF for traumatic spine injury. Future studies can investigate methods for patient risk optimization to reduce morbidity and mortality.

Predicting 30-day mortality after surgery for metastatic disease of the spine: the H2-FAILS score.

Scoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease. Using the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05. Predicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72-0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76. The H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis. Prognostic level III.

Relationship between lower urinary tract symptoms and frailty.

To elucidate the relationship between frailty and lower urinary tract symptoms (LUTS). We longitudinally evaluated the temporal changes and the relationships between frailty and LUTS in 247 community-dwelling adults (45 years or older) at baseline and at a 5-year follow-up. We used the Fried phenotype (phenotype-based frailty), 5-item modified frailty index (5i-mFI; comorbidity-based frailty), and frailty discriminant score (comprehensive frailty assessment) to evaluate frailty. LUTS were evaluated using the international prostate symptom score (IPSS) and overactive bladder symptom score (OABSS). We analyzed 247 participants with a median age of 60 years. The median IPSS and OABSS were significantly increased over the 5 years. The proportion of frail individuals did not increase significantly over the 5 years. Of the three frailty assessment tools, the 5i-mFI score significantly increased between 2014 and 2019. Multiple linear regression analyses showed that the 5i-mFI score was significantly associated with the severity of LUTS in 2014 to 5i-mFI in 2019 but not with 5i-mFI in 2014 to the severity of LUTS in 2019. The effect of LUTS on frailty might be greater than the effect of frailty on LUTS. Further large-scale studies are needed to elucidate the relationship between LUTS and frailty.

Frailty predicts hospital acquired infections after brain tumor resection: Analysis of 27,947 patients’ data from a prospective multicenter surgical registry.

BackgroundHospital acquired infections (HAIs) present a significant source of economic burden in the United States. The role of frailty as a predictor of HAIs has not been illustrated among patients undergoing craniotomy for brain tumor resection (BTR). MethodsThe American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2015 to 2019 to identify patients who underwent craniotomy for BTR. Patients were categorized as pre-frail, frail and severely frail using the 5-factor Modified Frailty Index (mFI-5). Demographics, clinical and laboratory parameters, and HAIs were assessed. A multivariate logistic regression model was created to predict the occurrence of HAIs using these variables. ResultsA total of 27,947 patients were assessed. 1772 (6.3 %) of these patients developed an HAI after surgery. Severely frail patients were more likely to develop an HAI in comparison to pre-frail patients (OR = 2.48, 95 % CI = 1.65–3.74, p < 0.001 vs. OR = 1.43, 95 % CI = 1.18–1.72, p < 0.001). Ventilator dependence was the strongest predictor of developing an HAI (OR = 2.96, 95 % CI = 1.86–4.71, p < 0.001). ConclusionBaseline frailty, by virtue of its ability to predict HAIs, should be utilized in adopting measures to reduce the incidence of HAIs.

Modified frailty index independently predicts morbidity in patients undergoing 3-column osteotomy.

Adult Spinal Deformity (ASD) includes a spectrum of spinal conditions that can be associated with significant pain and loss of function. While 3-column osteotomies have been the procedures of choice for ASD patients, there is also a substantial risk for complications. The prognostic value of the modified 5-item frailty index (mFI-5) for these procedures has not yet been studied. The goal of this study is to evaluate the association of mFI-5 with 30-day morbidity, readmission, and reoperation following a 3-column osteotomy. The National Surgical Quality Improvement Program (NSQIP) database was queried to identify patients undergoing 3-Column Osteotomy procedures from 2011-2019. Multivariate modeling was utilized to assess mFI-5 and other demographic, comorbidity, laboratory, and perioperative variables as independent predictors of morbidity, readmission, and reoperation. N = 971. Multivariate analysis revealed that mFI-5 = 1 (OR = 1.62, p = 0.015) and mFI-5 ≥ 2 (OR = 2.17, p = 0.004) were significant independent predictors of morbidity. mFI-5 ≥ 2 was a significant independent predictor of readmission (OR = 2.16, p = 0.022) while mFI-5 = 1 was not a significant predictor of readmission (p = 0.053). Frailty did not predict reoperation. Frailty as defined by mFI-5 strongly and independently predicted increased odds of postoperative morbidity for patients undergoing 3-column osteotomy as surgical intervention for ASD. Only mFI-5 ≥ 2 was a significant independent predictor of readmission, while frailty did not predict reoperation. Other variables independently predicted increased and decreased odds of postoperative morbidity, readmission, and reoperation. III.

A retrospective study on the relationship between 5 modified frailty index (5-mFI) and postoperative complications of gynecological elderly patients undergoing abdominal surgery

IntroductionAim to evaluate the application of 5 modified frailty index (5-mFI) in predicting postoperative complications in elderly gynecological patients undergoing abdominal surgery.MethodsA total of 294 elderly gynecological patients who were hospitalized in the affiliated Hospital of North Sichuan Medical College and underwent abdominal surgery from November 2019 to May 2022 were collected from the Union Digital Medical Record (UniDMR) Browser of the hospital. According to whether postoperative complications (infection, hypokalemia, hypoproteinemia, poor wound healing and intestinal obstruction) occurred, the patients were divided into complication group (n = 98) and non-complication group (n = 196). Univariate and multivariate logistic regression analysis were used to analyze the risk factors of complications in elderly gynecological patients undergoing abdominal surgery. The receiver operating characteristic (ROC) curve was used to determine the predictive value of the frailty index score in elderly gynecological patients with postoperative complications after abdominal surgery.ResultsPostoperative complications occurred in 98 of 294 elderly gynecological patients undergoing abdominal surgery, accounting for 33.3%, 5-mFI (OR1.63, 95%CI 1.07–2.46,P = 0.022), age (OR1.08,95%CI 1.02–1.15, P = 0.009), operation time (OR 1.01, 95%CI 1.00-1.01). P < 0.001) were independent risk factors for postoperative complications in elderly patients undergoing abdominal surgery, and the area under the curve of postoperative complications in elderly gynecological patients was 0.60. (95%CI: 0.53–0.67, P = 0.005)ConclusionFive modified frailty index can effectively predict the occurrence of postoperative complications in elderly gynecological patients.

Frailty is Not Associated with Worse Outcomes following Lower Extremity Angiograms for Limb Ischemia in Nonagenarians

Endovascular interventions are performed routinely with minimal risk in younger populations. The safety and efficacy of endovascular interventions in nonagenarians is under examined. We sought to examine the following (1) mortality and limb salvage rates in the nonagenarian population and (2) whether frailty was associated with outcomes following lower extremity (LE) interventions for both acute limb ischemia (ALI) and chronic limb threatening ischemia (CLTI). A retrospective review of patients ≥90years who underwent a LE angiogram for ALI or CLTI over a 12-year period at a single institution was performed. Primary outcomes were 30-day and 12-month limb salvage and mortality rates. Patient demographics, 30-day complications, and 12-month target vessel reintervention (TVR) were reviewed. Frailty scores were calculated using the 11-factor modified frailty index (MFI-11). From 2009 to 2021, 76 patients (36% male) with a mean age of 93 (range: 90-102) underwent endovascular procedures for ALI (n=13) and CLTI (n=63). 30-day amputation and mortality rates were 6% and 8%, respectively. Patient demographics, preoperative functional status, and TVR rates were not different between patients who had early amputation (≤30days) and those who achieved limb salvage. Seventy-two patients (94%) had follow-up data at 30days. There was an 8% mortality rate at 30days. Of those alive at 30days, 94% of patients had successful limb salvage. Fifty-eight patients had complete follow-up data at 12months. Of the patients alive at 12-month follow-up (75%), the limb salvage rate was 98%. Patients with amputation at 30days had a significantly higher mortality rate at 12months compared to those who did not (83% vs. 19%; P<0.01). Based on MFI-11 scoring, 35% of the population was considered frail (≥0.27). Frail patients did not have significantly different 30-day outcomes (limb salvage: 94% vs. 88%; mortality 8% vs. 9%, P=0.41 and 0.94, respectively) or 12-month outcomes (limb salvage: 82% vs. 94%; mortality: 32% vs. 22%, P=0.28 and 0.39, respectively). Endovascular procedures can be done safely in nonagenarians with low mortality and amputation rates. Patients with early amputation are at significantly higher risk of death at 12months. Frailty, as measured by a validated index, was not associated with early or late outcomes. When compared to immediate amputation, nonagenarian patients and their families should be counseled as to the benefit from a minimally invasive endovascular procedure.

A neural network analysis of the effect of high and low frailty index indicators on predicting elective surgery discharge destinations.

Frailty is frequently used by clinicians to help determine surgical outcomes. The frailty index, which represents the frequency of frailty indicators present in an individual, is one method for evaluating patient frailty to predict surgical outcomes. However, the frailty index treats all indicators of frailty that are used in the index as equivalent. Our hypothesis is that frailty indicators may be divided into groups of high and low-impact indicators and this separation will improve surgical discharge outcome prediction accuracy. Population data for inpatient elective operations was collected from the 2018 American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Artificial neural network (ANN) models trained using backpropagation are used to evaluate the relative accuracy for predicting surgical outcome of discharge destination using a traditional modified frailty index (mFI) or a new joint mFI that separates high-impact and low-impact indicators into distinct groups as input variables. Predictions are made across nine possible discharge destinations. A leave-one-out method is used to indicate the relative contribution of high and low-impact variables. Except for the surgical specialty of cardiac surgery, the ANN model using distinct high and low-impact mFI indexes uniformly outperformed the ANN models using a single traditional mFI. Prediction accuracy improved from 3.4% to 28.1%. The leave-one-out experiment shows that except for the case of otolaryngology operations, the high-impact index indicators provided more support when determining surgical discharge destination outcomes. Frailty indicators are not uniformly similar and should be treated differently in clinical outcome prediction systems.

Comparison of two frailty indices in predicting life-threatening morbidity and mortality among older patients undergoing elective high-risk abdominal surgery.

Frailty predicts an increased risk of postoperative morbidity and mortality. Comparison of the predictive performance between two deficit accumulation models of frailty, the modified frailty index (mFI) and the revised-Risk Analysis Index (RAI-rev), is poorly understood. This study compared the predictive abilities of the above two frailty indices in predicting life-threatening morbidity and mortality among older patients following elective high-risk abdominal surgery. This retrospective cohort study extracted perioperative data of older patients (age ≥65 years) undergoing elective high-risk abdominal surgery at a single institution between January 2018 and December 2020. Preoperative frailty was screened by mFI and RAI-rev scoring systems. The primary outcome was the composite of postoperative life-threatening morbidity and mortality during hospitalization. Multivariable logistic regression analyses were performed to investigate the association of the two frailty indices with the primary outcome. Receiver-operating characteristic (ROC) curve was employed to test the predictive performances of the two frailty instruments in predicting the composite primary outcome. The difference between the area under the curves (AUCs) was assessed by DeLong's test. 1,132 older patients (mean age, 73.4 ± 6.2 years; 63.9% male) were included. Of these, 107 (9.5%) developed postoperative life-threatening morbidity and mortality. In multivariable logistic regression analyses, rising continuous frailty scores (mFI: adjusted OR 1.319 per 0.09-point increase in score, 95% CI 1.151-1.511, p < 0.001; RAI-rev: adjusted OR 1.052 per 1-point increase in score, 95% CI 1.018-1.087, p = 0.002) as well as dichotomized frailty measures (mFI ≥0.27: adjusted OR 2.059, 95% CI 1.328-3.193, p = 0.001; RAI-rev ≥45: adjusted OR 1.862, 95% CI 1.188-2.919, p = 0.007) were associated with increased odds of the primary outcome separately. ROC curve analysis showed that the discrimination of mFI and RAI-rev scores for the life-threatening morbidity and mortality was poor and comparable (AUC: 0.598 [95% CI 0.569-0.627] vs. 0.613 [95% CI 0.583-0.641]; DeLong's test: Z = 0.375, p = 0.7075). High mFI and RAI-rev scores were associated with an increased risk of life-threatening morbidity and mortality in older patients undergoing elective high-risk abdominal surgery. However, both frailty indices displayed poor discrimination for postoperative life-threatening morbidity and mortality.