Whats New in the Patient Safety World
June 2014
Another Study Linking Frailty to Surgical Complications
Another of our
favorite soapbox topics: we focus on the wrong things preoperatively. For many
years (see our August 17, 2010 Patient Safety Tip of the Week Preoperative
Consultation Time to Change) we have recommended the need for
more focus on three things that impact surgical outcomes significantly:
obstructive sleep apnea, delirium, and frailty. Frailty, in particular, has
been associated with a variety of undesirable post-surgical outcomes (see the
list of our prior columns at the end of todays column).
Yet another new
study (Kim 2014)
demonstrates that a multidimensional frailty score can predict postoperative
mortality risk in elderly patients undergoing surgery. The researchers used
their own frailty tool, based on subsets of the Comprehensive Geriatric
Assessment (CGA), in patients aged 65 and older who were undergoing
intermediate- or high-risk elective surgery. Their scoring tool (referred to as the Multidimensional Frailty Score or
MFS) used malignant disease, the Charlson Comorbidity
Index, dependence in activities of daily living, dependence in instrumental
activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition risk as variables.
The key findings
were that the MFS score was predictive of 1-year all-cause mortality, length of
hospital stay, and likelihood of discharge to a nursing facility or long-term
care facility. And the higher the MFS score, the greater the likelihood of
mortality.
Technically, the Kim study did not demonstrate a statistically significant association between frailty and specific surgical complications (as opposed to mortality, length of stay and discharge to a nursing home or long-term care facility). But that was likely because the study was underpowered to show such association.
Most importantly,
their MFS score was considerably better than the time-honored ASA (American
Society of Anesthesiologists) score at predicting these unfavorable outcomes.
This study adds to
the many studies weve discussed in past columns demonstrating the link between
frailty and unfavorable surgical outcomes. While we have our doubts that
surgeons or primary care physicians will perform a full comprehensive geriatric
assessment preoperatively, dont forget that there are numerous shorter
assessments of frailty (eg. the timed up-and-go test)
that are very useful.
Some of our prior
columns on preoperative assessment and frailty:
- March 31, 2009 Screening
Patients for Risk of Delirium
- January 26, 2010 Preventing
Postoperative Delirium
- June 2010 The
Frailty Index and Surgical Outcomes
- August 17, 2010 Preoperative
Consultation Time to Change
- August 31, 2010 Postoperative
Delirium
- August 9, 2011 Frailty and the Surgical Patient
- September 2011 Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery)
- October 18, 2011 High
Risk Surgical Patients
- November 2011 Timed
Up-and-Go Test and Surgical Outcomes
- April 3, 2012 New
Risk for Postoperative Delirium: Obstructive Sleep Apnea
- August 7, 2012 Cognition, Post-Op Delirium, and Post-Op Outcomes
- August 14, 2012 Gait
Speed: A New Vital Sign?
- September 25, 2012 Preoperative
Assessment for Geriatric Patients
- September 3, 2013 Predicting
Perioperative Complications: Slow and Simple
- November 2013 Predicting
Perioperative Complications: Even Simpler!
References:
Kim S, Han J, Jung H, et al. Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg 2014; Published online May 07, 2014. doi:10.1001/jamasurg.2014.241
http://archsurg.jamanetwork.com/article.aspx?articleid=1867407
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