Journal of the American College of Surgeons
Volume 210, Issue 6 , Pages 901-908, June 2010

Frailty as a Predictor of Surgical Outcomes in Older Patients

  • Martin A. Makary, MD, MPH, FACS

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • Departments of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Corresponding Author InformationCorrespondence address: Martin A Makary, MD, MPH, Department of Surgery, Johns Hopkins Hospital, CRB II, Suite 507, 1550 Orleans St, Baltimore, MD 21231
    • ,
  • Dorry L. Segev, MD, PhD, FACS

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Peter J. Pronovost, MD, PhD

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • Department of Anesthesiology and Critical Care Medicine, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • Departments of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Dora Syin, MD

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Karen Bandeen-Roche, PhD

      Affiliations

    • Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Purvi Patel, MD, MPH

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Ryan Takenaga, MD

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins Center on Aging and Health, Department of Medicine, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Lara Devgan, MD, MPH

      Affiliations

    • Department of Surgery, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Christine G. Holzmueller, BLA

      Affiliations

    • Department of Anesthesiology and Critical Care Medicine, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Jing Tian, MS

      Affiliations

    • Johns Hopkins Center on Aging and Health, Department of Medicine, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Linda P. Fried, MD, MPH

      Affiliations

    • Johns Hopkins Center on Aging and Health, Department of Medicine, John Hopkins University School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD

Received 10 November 2009; received in revised form 20 January 2010; accepted 25 January 2010. published online 28 April 2010.

Background

Preoperative risk assessment is important yet inexact in older patients because physiologic reserves are difficult to measure. Frailty is thought to estimate physiologic reserves, although its use has not been evaluated in surgical patients. We designed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models.

Study Design

We prospectively measured frailty in 594 patients (age 65 years or older) presenting to a university hospital for elective surgery between July 2005 and July 2006. Frailty was classified using a validated scale (0 to 5) that included weakness, weight loss, exhaustion, low physical activity, and slowed walking speed. Patients scoring 4 to 5 were classified as frail, 2 to 3 were intermediately frail, and 0 to 1 were nonfrail. Main outcomes measures were 30-day surgical complications, length of stay, and discharge disposition. Multiple logistic regression (complications and discharge) and negative binomial regression (length of stay) were done to analyze frailty and postoperative outcomes associations.

Results

Preoperative frailty was associated with an increased risk for postoperative complications (intermediately frail: odds ratio [OR] 2.06; 95% CI 1.18–3.60; frail: OR 2.54; 95% CI 1.12–5.77), length of stay (intermediately frail: incidence rate ratio 1.49; 95% CI 1.24–1.80; frail: incidence rate ratio 1.69; 95% CI 1.28–2.23), and discharge to a skilled or assisted-living facility after previously living at home (intermediately frail: OR 3.16; 95% CI 1.0–9.99; frail: OR 20.48; 95% CI 5.54–75.68). Frailty improved predictive power (p < 0.01) of each risk index (ie, American Society of Anesthesiologists, Lee, and Eagle scores).

Conclusions

Frailty independently predicts postoperative complications, length of stay, and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models. Assessing frailty using a standardized definition can help patients and physicians make more informed decisions.

Abbreviations and Acronyms: ASA, American Society of Anesthesiology, AUC, area under the receiver operating characteristic curve, LOS, length of stay, NSQIP, National Surgical Quality Improvement Program

 

 Disclosure Information: Nothing to disclose.

 Supported by grants from the National Institutes of Health (grant 1T32RR023253-01), and the National Institute of Aging, Older Americans Independence Center (grant P30 AG021334); the Johns Hopkins Center for Innovative Medicine for a Cosner Scholar; the American Geriatrics Society Jahnigen Scholars Program, The Hartford Foundation; and the American Federation of Aging, Research Training in Aging Program and the Mr and Mrs Chad and Nissa Richison Family Foundation.

PII: S1072-7515(10)00059-1

doi:10.1016/j.jamcollsurg.2010.01.028

Journal of the American College of Surgeons
Volume 210, Issue 6 , Pages 901-908, June 2010

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