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 ) 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:
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
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