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Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations.

ABSTRACT: Importance:Growing consensus suggests that frailty-associated risks should inform shared surgical decision making. However, it is not clear how best to screen for frailty in preoperative surgical populations. Objective:To develop and validate the Risk Analysis Index (RAI), a 14-item instrument used to measure surgical frailty. It can be calculated prospectively (RAI-C), using a clinical questionnaire, or retrospectively (RAI-A), using variables from the surgical quality improvement databases (Veterans Affairs or American College of Surgeons National Surgical Quality Improvement Projects). Design, Setting, and Participants:Single-site, prospective cohort from July 2011 to September 2015 at the Veterans Affairs Nebraska-Western Iowa Heath Care System, a Level 1b Veterans Affairs Medical Center. The study included all patients presenting to the medical center for elective surgery. Exposures:We assessed the RAI-C for all patients scheduled for surgery, linking these scores to administrative and quality improvement data to calculate the RAI-A and the modified Frailty Index. Main Outcomes and Measures:Receiver operator characteristics and C statistics for each measure predicting postoperative mortality and morbidity. Results:Of the participants, the mean (SD) age was 60.7 (13.9) years and 249 participants (3.6%) were women. We assessed the RAI-C 10?698 times, from which we linked 6856 unique patients to mortality data. The C statistic predicting 180-day mortality for the RAI-C was 0.772. Of these 6856 unique patients, we linked 2785 to local Veterans Affairs Surgeons National Surgical Quality Improvement Projects data and calculated the C statistic for both the RAI-A (0.823) and RAI-C (0.824), along with the correlation between the 2 scores (r?=?0.478; P?

SUBMITTER: Hall DE

PROVIDER: S-EPMC7140150 | biostudies-literature | 2017 Feb

REPOSITORIES: biostudies-literature

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Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations.

Hall Daniel E DE Arya Shipra S Schmid Kendra K KK Blaser Casey C Carlson Mark A MA Bailey Travis L TL Purviance Georgia G Bockman Tammy T Lynch Thomas G TG Johanning Jason J

JAMA surgery 20170201 2

<h4>Importance</h4>Growing consensus suggests that frailty-associated risks should inform shared surgical decision making. However, it is not clear how best to screen for frailty in preoperative surgical populations.<h4>Objective</h4>To develop and validate the Risk Analysis Index (RAI), a 14-item instrument used to measure surgical frailty. It can be calculated prospectively (RAI-C), using a clinical questionnaire, or retrospectively (RAI-A), using variables from the surgical quality improvemen ...[more]

PMID: 27893030

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Project description:BackgroundFrailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown.ObjectiveValidate the RAI in ambulatory patients.Design, setting, and participantsObservational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy).Main outcomes and measuresAll-cause 1-year mortality, assessed by stratified Cox proportional hazard models.ResultsOf 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure.ConclusionRAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818-1824, 2020.

Project description:BackgroundPhysical frailty phenotype is characterized by decreased physiologic reserve to stressors and associated with poor outcomes, such as delirium and mortality, that may result from post-kidney transplant (KT) inflammation. Despite a hypothesized underlying pro-inflammatory state, conventional measures of frailty typically do not incorporate inflammatory biomarkers directly. Among KT candidates and recipients, we evaluated the inclusion of inflammatory biomarkers with traditional physical frailty phenotype components.MethodsAmong 1154 KT candidates and recipients with measures of physical frailty phenotype and inflammation (interleukin 6 [IL6], tumor necrosis factor alpha [TNFα], C-reactive protein [CRP]) at 2 transplant centers (2009-2017), we evaluated construct validity of inflammatory-frailty using latent class analysis. Inflammatory-frailty measures combined 5 physical frailty phenotype components plus the addition of an individual inflammatory biomarkers, separately (highest tertiles) as a sixth component. We then used Kaplan-Meier methods and adjusted Cox proportional hazards to assess post-KT mortality risk by inflammatory-frailty (n = 378); Harrell's C-statistics assessed risk prediction (discrimination).ResultsBased on fit criteria, a 2-class solution (frail vs nonfrail) for inflammatory-frailty was the best-fitting model. Five-year survival (frail vs nonfrail) was: 81% versus 93% (IL6-frailty), 87% versus 89% (CRP-frailty), and 83% versus 91% (TNFα-frailty). Mortality was 2.07-fold higher for IL6-frail recipients (95% CI: 1.03-4.19, p = .04); there were no associations between the mortality and the other inflammatory-frailty indices (TNFα-frail: 1.88, 95% CI: 0.95-3.74, p = .07; CRP-frail: 1.02, 95% CI: 0.52-2.03, p = .95). However, none of the frailty-inflammatory indices (all C-statistics = 0.71) improved post-KT mortality risk prediction over the physical frailty phenotype (C-statistics = 0.70).ConclusionsMeasurement of IL6-frailty at transplantation can inform which patients should be targeted for pre-KT interventions. However, the traditional physical frailty phenotype is sufficient for post-KT mortality risk prediction.

Project description:ImportanceFrailty based on the modified Frailty Index is associated with poor postoperative outcomes. However, the index requires high levels of personnel time and effort and often has missing data.ObjectiveTo evaluate the association of the Memorial Sloan Kettering-Frailty Index (MSK-FI) with established geriatric assessment (GA) and surgical outcomes.Design, setting, and participantsThis cohort study included prospectively evaluated patients with cancer 75 years and older who were referred to MSK Geriatrics Service clinics for preoperative evaluation before undergoing surgery requiring hospitalization between February 2015 and September 2017. Patients were comanaged by the Geriatrics Service and Surgery Service in the postoperative period.ExposuresImpairments identified by GA and comorbid conditions retrieved from submitted International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes within the first 48 hours of hospitalization.Main outcomes and measuresThe association of MSK-FI score (which included ICD-9 and ICD-10 codes) with GA impairments (based on clinical interview and examination as well as patient reports) was examined. The associations of MSK-FI score with short-term surgical outcomes (ie, frequency of complications, length of stay, 30-day surgical complications, 30-day intensive care unit admissions, and 30-day readmissions) and 1-year survival, estimated by Kaplan-Meier methods, were determined.ResultsIn total, 1137 patients (median [interquartile range] age, 80 [77-84] years; 583 [51.2%] women) were included in the study. A higher MSK-FI score was associated with the number of GA impairments (ρ = 0.52; bootstrapped 95% CI, 0.47-0.56). Each 1-point increase in MSK-FI score was associated with longer length of stay (0.58 d; 95% CI, 0.22-0.95; P = .002) and higher odds of intensive care unit admission (odds ratio, 1.28; 95% CI, 1.04-1.58; P = .02). Median (interquartile range) follow-up among survivors was 12.1 (5.6-19.1) months. The MSK-FI score was associated with overall mortality; 12-month risk of death was 5% for a score of 0 and approximately 20% for scores of 4 and higher (nonlinear association, P = .005).Conclusions and relevanceIn this study, the MSK-FI was associated with the previously validated GA and postoperative outcomes in older patients with cancer and may be a feasible tool for perioperative assessment of older surgical patients with cancer. Future studies should assess the association of MSK-FI score with postoperative care and outcomes of older, frail patients with cancer.

Project description:ObjectivesFrailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.DesignA rapid review of primary studies was conducted.Data sourcesFour databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.Eligibility criteriaEligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.Data extraction and synthesisRecords were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.ResultsWe identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.ConclusionsLimited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.

Dataset Information

Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations.

Publications

Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations.

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