Frailty Screening Initiative Associated with Improved Post-Operative Survival among Veterans
Many patients older than 65 years of age undergo surgery, and recent data demonstrate that frailty is a more powerful predictor of increased perioperative mortality, morbidity, and cost than predictions based on age or comorbidity alone. The Surgical Service Line at the Nebraska Western-Iowa (NWI) VAMC in Omaha, NE conducts 3,600 operations annually, of which 42% of the patients are 65 years of age or older. In 2011, the Chief of Surgery for the NWI VAMC designed and implemented a Frailty Screening Initiative (FSI) aimed at improving post-operative survival. The FSI consists of two parts: 1) screening for frailty with the goal of rapid assessment without the need for access to a patient's chart, and 2) review of surgical decision-making. This prospective cohort study assessed the impact of the FSI on mortality and complications by comparing surgical outcomes before and after implementation of the FSI. Study participants included all Veterans presenting for major, elective, non-cardiac surgery at the NWI VAMC between October 1, 2007 and July 1, 2014 (n=9,153). The main outcome measure was post-operative mortality at 30, 180, and 365 days.
- Implementing frailty screening was associated with reduced mortality, suggesting both the feasibility of widespread screening of patients pre-operatively to identify frailty – and the efficacy of system-level initiatives aimed at improving their surgical outcomes.
- Overall, 30-day mortality dropped from 1.6% to 0.7% after FSI implementation. Improvement was greatest among the frail (12% to 4%). Moreover, the magnitude of improvement among frail patients increased at 180 (24% to 8%) and 365 days (35% to 12%).
- After controlling for age, frailty, and predicted mortality, multivariate models showed that the FSI resulted in a three-fold survival benefit in this study cohort.
- Frailty screening of preoperative patients is feasible, and may be an effective and scalable tool for improving surgical outcomes for aging and increasingly frail U.S. and Veteran populations.
- Because study data could not quantify how the FSI changed perioperative decision-making, it is likely some frail patients did not go on to have surgery, and are thus not included in this analysis. This potential selection bias could explain some of the effect.
- The FSI intervention did not adhere to a formal post-operative intervention or prehabilitation protocol, thereby limiting investigators' ability to infer the casuative factor behind improvement.
Dr. Hall was supported by an HSR&D Career Development Award (CDA 08-281) and is part of HSR&D's Center for Health Equity Research & Promotion (CHERP) in Pittsburgh, PA.
Hall D, Arya S, Schmid K, et al. Association of Frailty Screening Initiative with Post-Operative Survival at 30, 180 and 365 days. JAMA Surgery. November 30, 2016;e-pub ahead of print.