Predicting outcomes in elderly patients undergoing surgery has not been an easy task and often the elderly have complications and long lengths of hospital stay after surgery. Many lose their ability to function independently and some form of assisted living after surgery. Being able to accurately predict who will not fare well after surgery would greatly assist in the decision to undergo surgery and to plan for likely contingencies in those who need surgery. Current methods of predicting postoperative complications have had limited success.
Now a new study (Makary et al 2010) has demonstrated that use of the frailty index greatly improves the ability to predict post-surgical outcomes much better than existing methods.
The frailty index uses a score of 0 or 1 for each of five domains: weight loss, weakness, low physical activity, exhaustion, and slow walking speed. It takes about 10 minutes to administer the frailty index. Weakness is measured with a hand ergometer. Walking speed is measured by having the patient walk 15 feet and timing them. Weight loss is 10 or more pounds lost unintentionally in the past year. And the other 2 domains are assessed by asking simple questions. Patients scoring 4-5 are classified as being frail, those scoring 2-3 as intermediately frail. The frailty index has been validated and been predictive of outcomes in medical patients. However, the research group at Johns Hopkins assessed the ability of this index done preoperatively to predict certain post-surgical outcomes.
The frailty index turned out to be very good in its ability to predict surgical outcomes. For instance, the odds ratio for frail patients for postoperative complications after major surgery was 2.54, for length of stay 1.69, and for discharge to a skilled nursing facility or assisted living facility 20.48. Odds ratios for those with intermediate frailty were somewhat lower but still predictive of all the above. And the frailty index was better than other tools used to predict outcomes (ASA score, Lee’s revised cardiac risk index, and the Eagle score). Adding the frailty index to any of those tools significantly improved the predictability of outcomes.
It will be very interesting to see how the frailty index fares in other settings (eg. community hospitals, etc.). This could be an extremely helpful tool in helping to avoid some of the pain and suffering that occurs with surgery in the elderly and at least serve as a tool to help patients and families anticipate what to expect in patients undergoing surgery.
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010;