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Publication Briefs

Study Shows Frailty Associated with Post-Operative Mortality across All Non-Cardiac Surgical Specialties

Frailty is increasingly recognized as an important risk factor for adverse post-operative outcomes. Frail patients experience higher rates of adverse outcomes such as complications, failure to rescue, non-home discharge, and short- and long-term mortality. Although prior work has demonstrated the association of frailty and patient-level outcomes, it is unclear how this translates to populations of patients treated by different specialties. Also, the degree to which frailty screening would be useful for peri-operative risk stratification and the prevalence of frailty in each surgical specialty is unknown. This cohort study sought to determine the relationship between frailty and post-operative mortality across nine non-cardiac surgical specialties. Using data from the National Surgical Quality Improvement Program (NSQIP) and VA’s Surgical Quality Improvement Program (VASQIP) from January 2010 through December 2014, investigators identified patients who underwent non-cardiac surgery during this time period (2,239,031 procedures in NSQIP and 426,578 procedures in VASQIP). Non-cardiac surgical specialties included in the analysis were: general, gynecologic, neurologic, orthopedic, otolaryngologic, plastic, thoracic, urologic, and vascular surgery. The main outcome measured was 30- and 180-day (VASQIP only) post-operative mortality. Using a validated tool for measuring frailty in surgical and non-surgical populations (Risk Analysis Index, RAI), investigators categorized patients as Robust, Normal, Frail, and Very Frail. In addition, the operative stress of each case was rated using the Operative Stress Score, a previously validated scoring system.


  • Frailty was associated with post-operative mortality across all non-cardiac surgical specialties independent of operative stress. Frail patients in all surgical specialties had high mortality rates following low- and moderate-stress procedures.
  • Approximately 1 out of 10 Frail patients and 1 out of 3 Very Frail patients die six months following low-, moderate-, and high-stress procedures in all specialties.


  • Pre-operative frailty assessment should be implemented across all specialties, regardless of case-mix, to facilitate risk stratification and shared decision-making.


  • Underlying data is de-identified at the case level, thereby preventing analysis at the patient level.
  • VASQIP and NSQIP do not distinguish between all-cause mortality and deaths directly related to the surgical procedure. However, the authors contend that the cause of frailty-related mortality is less important than the awareness that mortality risks of any cause are substantial and, thus, relevant to setting realistic goals of care.

This study was partly funded by HSR&D. Drs. George and Arya are part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA, and Dr. Hall is part of HSR&D’s Center for Health Equity, Research and Promotion (CHERP), Pittsburgh, PA

George E, Hall D, Youk A, et al. Association Between Patient Frailty and Postoperative Mortality across Multiple Non-Cardiac Surgical Specialties. JAMA Surgery. November 18, 2020; Epub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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