Preoperative frailty associated with increased risk of death following surgery

Daniel I. McIsaac, M.D., M.P.H., F.R.C.P.C., of the University of Ottawa, Ontario, Canada, and colleagues measured the effect of patient frailty on, and its association with, 1-year postoperative mortality in a population-based study in Ontario. All patients were community-dwelling individuals age 65 years or older on the day of elective, major noncardiac surgery. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator.

Of 202,811 patients, 6,289 (3 percent) were frail (average age, 77 years). In the year after surgery, 855 frail patients (14 percent) compared with 9,433 nonfrail patients (5 percent) died. Adjusting for age, sex, neighborhood income quintile, and procedure, 1-year mortality risk remained significantly higher in the frail group. The association between frailty and mortality varied significantly by time, patient age, and surgery type. An interaction between frailty and postoperative time suggests that the early postoperative period is a window of markedly increased risk of mortality for frail elderly patients.

The authors write that patients, families, and clinicians must be aware of the absolute increase in frailty-related mortality risk. "The 1-year mortality rate for patients having elective nephrectomy, cystectomy, large-bowel surgery, liver resection, peripheral arterial bypass, esophagectomy or gastrectomy, or pancreaticoduodentectomy was at least 1 death per 5 frail patients. While the choice to proceed with an elective surgery must be weighed on a case-by-case basis, our findings support the need for thorough considerations of risk vs benefit and the overall goals of care in frail patients considering major surgery."

"Our findings suggest specific areas of focus for clinical and research efforts aimed at improving the care and outcomes of frail elderly surgical patients."

Commentary: Frailty and Mortality After Noncardiac Surgery in Elderly Individuals

"With this rigorous population-based, retrospective cohort study of surgical patients in Ontario, Canada, McIsaac and colleagues add to the growing literature demonstrating markedly increased risks frailty imposes on surgical populations," write Jason M. Johanning, M.D., M.S., of the Nebraska Western Iowa VA Medical Center, Omaha, and colleagues, in an accompanying commentary.

"Our assessment of the growing surgical literature on frailty mirrors the metaphor of blind men in a room each describing the smooth, hairy, or rough portion of the beast nearest at hand. Regardless of how frailty is measured, it still paints a picture of the same elephant: dramatically increased risks for postoperative mortality and morbidity. The elephant is now in our examination room and we, as surgeons, must address the optimal goals of care and honor patients' preferences. Yet the systems we will use and the metrics to ensure success remain to be seen."