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A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement.

ABSTRACT: BACKGROUND:Aortic valve replacement is a high-risk surgery (3%-5%, 30-day mortality) performed on approximately 30,000 elderly patients a year in the United States. Currently, preoperative risk assessment is based on a composite of medical examination and a subjective evaluation for frailty ("eyeball test"). Objective frailty assessment using validated indices has the potential to improve risk stratification. The purpose of this study was to (1) establish whether frailty can predict 30-day mortality and composite morbidity in patients undergoing aortic valve replacement and (2) compare the predictive ability of 3 frailty indices in this population. METHODS:This study was a retrospective cohort study of 3088 patients 65 years old and older undergoing aortic valve replacement surgery (based on current procedure terminology codes) between the years 2006 and 2012 extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index, risk analysis index, and Ganapathi indices. Outcomes measured were 30-day mortality and composite morbidity (myocardial infarction, cardiac arrest, pulmonary embolism, pneumonia, reintubation, renal insufficiency, coma >24 hours, urinary tract infections, sepsis, deep vein thrombosis, deep wound surgical site infection, superficial site infection, and reoperation). RESULTS:Frailty was a better predictor of mortality than morbidity, and it was not markedly different among any of the 3 indices. Frailty was associated with an increased risk of 30-day mortality and longer lengths of stay. CONCLUSIONS:Frailty can predict mortality in patients undergoing aortic valve replacement. Choice of frailty index does not make a difference in this patient population.

SUBMITTER: Esses G

PROVIDER: S-EPMC6457243 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement.

Esses Gary G Andreopoulos Evie E Lin Hung-Mo HM Arya Shipra S Deiner Stacie S

Anesthesia and analgesia 20180101 1

<h4>Background</h4>Aortic valve replacement is a high-risk surgery (3%-5%, 30-day mortality) performed on approximately 30,000 elderly patients a year in the United States. Currently, preoperative risk assessment is based on a composite of medical examination and a subjective evaluation for frailty ("eyeball test"). Objective frailty assessment using validated indices has the potential to improve risk stratification. The purpose of this study was to (1) establish whether frailty can predict 30-d ...[more]

PMID: 28857797

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Project description:BackgroundThe approved use of transcatheter aortic valve replacement (TAVR) for aortic stenosis has expanded substantially over time. However, gaps remain with respect to accurately delineating risk for poor clinical and patient-centered outcomes. Our objective was to develop prediction models for 30-day clinical and patient-centered outcomes after TAVR within a large, diverse community-based population.MethodsWe identified all adults who underwent TAVR between 2013-2019 at Kaiser Permanente Northern California, an integrated healthcare delivery system, and were monitored for the following 30-day outcomes: all-cause death, improvement in quality of life, all-cause hospitalizations, all-cause emergency department (ED) visits, heart failure (HF)-related hospitalizations, and HF-related ED visits. We developed prediction models using gradient boosting machines using linked demographic, clinical and other data from the Society for Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT Registry and electronic health records. We evaluated model performance using area under the curve (AUC) for model discrimination and associated calibration plots. We also evaluated the association of individual predictors with outcomes using logistic regression for quality of life and Cox proportional hazards regression for all other outcomes.ResultsWe identified 1,565 eligible patients who received TAVR. The risks of adverse 30-day post-TAVR outcomes ranged from 1.3% (HF hospitalizations) to 15.3% (all-cause ED visits). In models with the highest discrimination, discrimination was only moderate for death (AUC 0.60) and quality of life (AUC 0.62), but better for HF-related ED visits (AUC 0.76). Calibration also varied for different outcomes. Importantly, STS risk score only independently predicted death and all-cause hospitalization but no other outcomes. Older age also only independently predicted HF-related ED visits, and race/ethnicity was not significantly associated with any outcomes.ConclusionsDespite using a combination of detailed STS/ACC TVT Registry and electronic health record data, predicting short-term clinical and patient-centered outcomes after TAVR remains challenging. More work is needed to identify more accurate predictors for post-TAVR outcomes to support personalized clinical decision making and monitoring strategies.

Project description:ImportanceHospital outcomes for transcatheter aortic valve replacement (TAVR) may be dependent on the quality of evaluation, personnel, and procedural and postprocedural care common to patients undergoing cardiac surgery.ObjectivesWe sought to assess whether those hospitals with better patient outcomes for surgical aortic valve replacement (SAVR) subsequently achieved better TAVR outcomes after launching TAVR programs.Design, setting, and participantsThis national cohort included US patients 65 years and older. The analysis used the Centers for Medicare and Medicaid Services' Medicare Provider and Review data collected between January 1, 2010, and September 29, 2015. Only hospitals performing at least 1 SAVR prior to September 1, 2011, and performing at least 1 TAVR after this date were included in the analysis. Data analysis was completed from June 2018 to August 2018.InterventionsIsolated aortic valve replacements.Main outcomes and measuresHospital risk-adjusted 30-day mortality for SAVR in the pre-TAVR period was used as a surrogate for SAVR quality. Thirty-day and 1-year TAVR mortality rates were examined after stratification by quartile of baseline hospital risk-adjusted SAVR mortality.ResultsA total of 51 924 TAVR procedures were performed in 519 hospitals, of which 19 798 were performed at hospitals in quartile 1 (the lowest risk-adjusted SAVR mortality rate), 7663 were performed in quartile 2, 10 180 were performed in quartile 3, and 14 283 were performed in quartile 4 (the highest risk-adjusted SAVR mortality rate). Observed mortality rates at 30 days consistently increased with increasing baseline hospital SAVR risk-adjusted mortality (quartile 1, 917 patients [4.6%]; quartile 2, 381 [5.0%]; quartile 3, 521 [5.1%]; quartile 4, 800 [5.6%]; P < .001). The same pattern was observed in 1-year mortality (quartile 1, 3359 [17.0%]; quartile 2, 1337 [17.5%]; quartile 3, 1852 [18.2%]; quartile 4, 2652 [18.6%]; P < .001). After multivariable analysis, compared with the lowest quartile of SAVR mortality, undergoing TAVR at a hospital with higher baseline SAVR mortality continued to be associated with higher 30-day mortality (odds ratios: quartile 2, 1.02 [95% CI, 0.87-1.21]; quartile 3, 1.13 [95% CI, 1.02-1.26]; quartile 4, 1.23 [95% CI, 1.07-1.40]; P = .02) and 1-year mortality (hazard ratios: quartile 2, 1.04 [95% CI, 0.92-1.17]; quartile 3, 1.14 [95% CI, 1.02-1.28]; quartile 4, 1.16 [95% CI, 1.05-1.28]; P = .02).Conclusions and relevanceHospitals with higher SAVR mortality rates also had higher short-term and long-term TAVR mortality after initiating TAVR programs. Quality of cardiac surgical care may be associated with a hospital's performance with new structural heart disease programs.

Project description:Background Frailty predicts an increased risk of postoperative morbidity and mortality. Comparison of the predictive performance between two deficit accumulation models of frailty, the modified frailty index (mFI) and the revised-Risk Analysis Index (RAI-rev), is poorly understood. This study compared the predictive abilities of the above two frailty indices in predicting life-threatening morbidity and mortality among older patients following elective high-risk abdominal surgery. Methods This retrospective cohort study extracted perioperative data of older patients (age ≥65 years) undergoing elective high-risk abdominal surgery at a single institution between January 2018 and December 2020. Preoperative frailty was screened by mFI and RAI-rev scoring systems. The primary outcome was the composite of postoperative life-threatening morbidity and mortality during hospitalization. Multivariable logistic regression analyses were performed to investigate the association of the two frailty indices with the primary outcome. Receiver-operating characteristic (ROC) curve was employed to test the predictive performances of the two frailty instruments in predicting the composite primary outcome. The difference between the area under the curves (AUCs) was assessed by DeLong’s test. Results 1,132 older patients (mean age, 73.4 ± 6.2 years; 63.9% male) were included. Of these, 107 (9.5%) developed postoperative life-threatening morbidity and mortality. In multivariable logistic regression analyses, rising continuous frailty scores (mFI: adjusted OR 1.319 per 0.09-point increase in score, 95% CI 1.151–1.511, p < 0.001; RAI-rev: adjusted OR 1.052 per 1-point increase in score, 95% CI 1.018–1.087, p = 0.002) as well as dichotomized frailty measures (mFI ≥0.27: adjusted OR 2.059, 95% CI 1.328–3.193, p = 0.001; RAI-rev ≥45: adjusted OR 1.862, 95% CI 1.188–2.919, p = 0.007) were associated with increased odds of the primary outcome separately. ROC curve analysis showed that the discrimination of mFI and RAI-rev scores for the life-threatening morbidity and mortality was poor and comparable (AUC: 0.598 [95% CI 0.569–0.627] vs. 0.613 [95% CI 0.583–0.641]; DeLong’s test: Z = 0.375, p = 0.7075). Conclusion High mFI and RAI-rev scores were associated with an increased risk of life-threatening morbidity and mortality in older patients undergoing elective high-risk abdominal surgery. However, both frailty indices displayed poor discrimination for postoperative life-threatening morbidity and mortality.

Dataset Information

A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement.

Publications

A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement.

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