Weve long advocated major change in the way we prepare patients, particularly the elderly, for surgery (see our August 17, 2010 Patient Safety Tip of the Week and the multiple columns listed at the end of this column). Historically the pre-op workup has included multiple testing that has little impact on patient outcomes. Unfortunately, past habits are hard to break and we continue to see lots of unnecessary testing and lack of focus on potentially more meaningful evaluations. For example, identification of patients at risk for delirium, those who are frail, and those who have diagnosed or undiagnosed sleep apnea is much more likely to identify patients at risk for complications than doing extensive cardiac studies in patients lacking a history of heart disease.
There has been some progress in doing a more streamlined assessment to predict the risk of complications in patients undergoing surgery. This past year the ACS NSQIP Surgical Risk Calculator has received some attention as a relatively simple-to-administer tool to help predict surgical risk based upon nature of the surgical procedure and assessment of multiple patient risk factors. Based on data from over 1.4 million patients in the American College of Surgeons NSQIP database, the calculator has been shown to be useful in predicting complications for most common surgical procedures (Bilimoria 2013). We think that this is an excellent tool and should be used in just about all patients contemplating surgery. We expect that surgeons will use the estimated risk prediction in their informed consent discussions with their patients.
But we still need to address simplification and optimization of the pre-op evaluations commonly performed by primary care physicians. Weve done multiple columns on the ability of measures of frailty to predict postoperative complications, morbidity and mortality, and discharge to institutional settings. We have previously highlighted the contributions by Makary and colleagues (Makary et al 2010) and Robinson and colleagues in predicting postoperative complications based on frailty measures (Robinson 2009, Robinson 2011).
Now Robinson and colleagues have again demonstrated in two new studies the value of measures of frailty in predicting postoperative complications and morbidity. In the first study (Robinson 2013a) the authors looked at 7 frailty traits in patients 65 years or older who were undergoing either major colorectal surgery or cardiac surgery. The frailty traits were a Katz score less than or equal to 5, Timed Up and Go test greater than or equal to 15 seconds, Charlson Index greater than or equal to 3, anemia less than 35%, Mini-Cog score less than or equal to 3, albumin less than 3.4 g/dL, and 1 or more falls within 6 months. Patients were considered nonfrail if they had 0 to 1 of these traits, prefrail if they had 2 to 3 traits, and frail if they had 4 or more traits. Preoperative frailty was associated with increased postoperative complications after colorectal (nonfrail: 21%, prefrail: 40%, frail: 58%) and cardiac operations (nonfrail: 17%, prefrail: 28%, frail: 56%). The findings remained significant even after adjustment for age. Frail individuals in both groups also had longer hospital stays and higher 30-day readmission rates.
In the second study (Robinson 2013b) the authors looked at the ability of the Timed Up and Go test (see our November 2011 Whats New in the Patient Safety World column Timed Up-and-Go Test and Surgical Outcomes) to predict postoperative morbidity and 1-year mortality, and to compare the Timed Up and Go to the standard-of-care surgical risk calculators for prediction of postoperative complications. The Timed Up and Go test was performed preoperatively in a cohort of patients 65 years and older undergoing elective colorectal and cardiac operations. This timed test starts with the subject standing from a chair, walking 10 feet, returning to the chair, and ends after the subject sits. Timed Up and Go results were grouped as fast <= 10 seconds, intermediate = 11-14 seconds, and slow >= 15 seconds.
They found that slower Timed Up and Go predicted increased postoperative complications and 1-year mortality across surgical specialties and that, regardless of operation performed, the Timed Up and Go compared favorably to more complex risk calculators at forecasting postoperative complications.
For colorectal surgery patients the rates of postoperative complications were 13%, 29%, and 77% for the fast, intermediate, and slow categories respectively. For cardiac surgery patients the rates of postoperative complications were 11%, 26%, and 52% for the fast, intermediate, and slow categories respectively.
The authors note that the Timed Up and Go detects multidimensional clinical deficits of the older adult, capturing the broader concept of frailty. For example, a slower Timed Up and Go is closely related with impaired cognition. They also note that there is a close correlation between the Time Up and Go and gait speed in general.
However, since we stress the value of evidence-based medicine, we need to ask the question Does the ability to predict this increased risk of complications make a difference in outcomes?. Robinson and colleagues are quick to point out that, to date, there is no evidence that suggests measurement of a preoperative Timed Up and Go can improve outcomes. They suggest a logical step after identification of a slow Time Up and Go test result might be pre-op physical therapy but such has not been shown to reduce complications or mortality in previous studies. However, since the test is really a measure of more global capacity we really would not expect an intervention aimed purely at mobility improvement to alter outcomes substantially. Rather, we might expect that upon identification of a slow Timed Up and Go test result patients might be shunted into a program like HELP (the Hospital Elder Life Program). In our September 2011 Whats New in the Patient Safety World column Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery we discussed studies (, Chen 2011) demonstrating improved outcomes after such multicomponent interventions.
The Timed Up and Go or gait speed in general have utility far beyond just predicting surgical complications. In our August 14, 2012 Patient Safety Tip of the Week Gait Speed: A New Vital Sign? we noted the relationship between gait slowness and overall survival, cognitive dysfunction, and others. A couple new studies published this year also demonstrate the utility of gait speed measurement. One study (Roshanravan 2013) in patients with stage 2-4 CKD showed that adding gait speed to a model that included estimated GFR significantly improved the prediction of 3-year mortality. Another (Chaudhry 2013) showed that CHF patients with slow gait were 28% more likely to be hospitalized for heart failure than those without slow gait.
Determination of walking speed is a simple, quick and inexpensive test easily performed in any office setting. A recent Spanish study (Castell 2013) found that measurement of walking speed is a good indicator of health and survival in older adults, especially after age 75. They found that a walking speed of ≥0.9 m/s rules out the presence of frailty, and that a walking speed of ≤0.8 m/s doubles the probability of a diagnosis of frailty.
Isnt it time that we begin to incorporate such simple objective measures into our routine assessments of patients, particularly the elderly?
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
· August 31, 2010
· 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
ACS NSQIP Surgical Risk Calculator
Bilimoria KY, Liu Y, Paruch JL, et al. Development and Evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A Decision Aide and Informed Consent Tool for Patients and Surgeons. J American College of Surgeons 2013; Published online 17 July 2013
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; 210(6): 901-908, June 2010
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011
Robinson TN, Wu DS, Pointer L, et al. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg 2013; published online 22 July 2013
Robinson TN, Wu DS, Sauaia A, et al. Slower Walking Speed Forecasts Increased Postoperative Morbidity and 1-Year Mortality Across Surgical Specialties. Annals of Surgery 2013; Published ahead of print 23 August 2013
Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676
Chen C C-H, Lin M-T, Tien Y-W, Yen C-J, Huang G-H, Inouye SK. Modified Hospital Elder Life Program: Effects on Abdominal Surgery Patients. J Amer Coll Surg 2011; 213(2): 245-252
Roshanravan B, Robinson-Cohen C, Patel KV, et al. Association between Physical Performance and All-Cause Mortality in CKD. JASN 2013; April 30, 2013 24: 822-830; published ahead of print April 18, 2013, doi:10.1681/ASN.2012070702
Chaudhry SI, Gail McAvay G, Chen S, et al. Risk Factors for Hospital Admission Among Older Persons With Newly Diagnosed Heart Failure: Findings From the Cardiovascular Health Study. J Am Coll Cardiol 2013; 61(6): 635-642. doi:10.1016/j.jacc.2012.11.027
Castell M-V, Sαnchez M, Juliαn R, et al. Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care. BMC Family Practice 2013; 14:86 (19 June 2013)
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