Publications

PURPOSE

We sought to determine whether frailty affects the type of pelvic organ prolapse surgery performed and the odds of postoperative complications.

MATERIALS AND METHODS

This is a retrospective cohort study of women who underwent obliterative and reconstructive surgery for pelvic organ prolapse in ACS (American College of Surgeons) NSQIP® (National Surgical Quality Improvement Program) from 2005 to 2013. We quantified frailty using NSQIP-FI (Frailty Index) and applied logistic regression models predicting the type of procedure (colpocleisis) and the odds of postoperative complications.

RESULTS

We identified a total of 12,731 women treated with pelvic organ prolapse repair, of which 5.3% were colpocleisis procedures, from 2005 to 2013. Among women undergoing colpocleisis, the average age was 79.2 years and 28.5% had a NSQIP-FI of 0.18 or higher, indicating frailty. Women undergoing colpocleisis procedures had higher odds of being frail (NSQIP-FI 0.18 vs 0 OR 1.9, 95% CI 1.4-2.6) and were older (age 85+ vs less than 65 years OR 486.4, 95% CI 274.6-861.7). For all types of pelvic organ prolapse procedures, frailty increased the odds of complications (NSQIP-FI 0.18 vs 0 OR 2.8, 95% CI 1.8-3.0), after adjusting for age and type of pelvic organ prolapse procedure.

CONCLUSIONS

For pelvic organ prolapse surgery, age rather than frailty is more strongly associated with the type of procedure performed. However, frailty is more strongly associated with postoperative complications than age. Furthermore, incorporating frailty into preoperative decision making is important to improve expectations and outcomes among older women considering pelvic organ prolapse surgery.

Trials of enhanced recovery programs suggest that multimodality pain regimens improve outcomes after colorectal surgery. We sought to determine whether patients receiving postoperative multimodality pain regimens would have shorter lengths of stay without an associated increase in readmission rate as compared to those receiving opioid-based pain regimens. Retrospective cohort study of adults who underwent elective colorectal surgery between January 1, 2006, and December 31, 2012, in a national hospital network participating in the Premier Perspective database. Patients were grouped into multimodality or opioid-based using postoperative medication charges. Primary outcome measures included length of stay and 30-day readmission rate. Among 91,936 patients, 38 per cent received multimodality pain regimens and 61 per cent received opioid-based regimens. After adjustment for patient and surgical characteristics, there was no difference in length of stay or cost, odds of readmission were 1.2 (95% confidence interval = 1.2-1.3, P < 0.001), and odds of mortality were 0.8 (95% confidence interval = 0.6-0.9, P < 0.001) in the multimodality group compared to nonopioid sparing. Our results were consistent in secondary analyses using propensity matching. Fewer than half of patients undergoing elective colorectal surgery in our cohort received multimodality pain regimens, and receipt of these medications was associated with mixed benefits in terms of length of stay, readmission, and mortality.

OBJECTIVE

To evaluate the prevalence of frailty, a known predictor of poor outcomes, among patients presenting to an academic nononcologic urology practice and to examine whether frailty differs among patients who did and did not undergo urologic surgery.

METHODS

The Timed Up and Go Test (TUGT), a parsimonious measure of frailty, was administered to patients ages ≥65. The TUGT, demographic data, urologic diagnoses, and procedural history were abstracted from the medical record into a prospective database. TUGT times were categorized as nonfrail (≤10 seconds), prefrail (11-14 seconds), and frail (≥15 seconds). These times were evaluated across age and urologic diagnoses and compared between patients who did and did not undergo urologic surgery using chi-square and t tests.

RESULTS

The TUGT was recorded for 78.9% of patient visits from December 2015 to May 2016. For 1089 patients, average age was 73.3 ± 6.3 years; average TUGT time was 11.6 ± 6.0 seconds; 30.0% were categorized as prefrail and 15.2% as frail. TUGT times increased with age, with 56.9% of patients age 86 and over categorized as frail. Times varied across diagnoses (highest average TUGT was 14.3 ± 11.9 seconds for patients with urinary tract infections); however, no difference existed between patients who did and did not undergo surgery (P = .94).

CONCLUSION

Among our population, prefrailty and frailty were common, TUGT times increased with age and varied by urologic diagnosis, but did not differ between patients who did and did not undergo urologic surgery, presenting an opportunity to consider frailty in preoperative surgical decision making.

OBJECTIVE

To understand the relationship between age, frailty, and overactive bladder (OAB).

MATERIALS AND METHODS

This is a prospective study of individuals age ≥65 years presenting to an academic urology practice between December 2015 and July 2016. All patients had a Timed Up and Go Test (TUGT), a parsimonious measure of frailty, on intake, and were thereby categorized as fast (≤10 seconds), intermediate (11-14 seconds), and slow (≥15 seconds). The TUGT and other clinical data were abstracted from the electronic medical record using direct queries. Logistic regression was used to examine the relationship between frailty and the diagnosis of OAB, adjusting for age, gender, and race.

RESULTS

Our cohort included 201 individuals with and 1162 individuals without OAB. Individuals with OAB had slower TUGTs (13.7 ± 7.9 seconds) than their non-OAB counterparts (10.9 ± 5.2 seconds), P <.0001, with 32.3% and 11.0% of OAB and non-OAB individuals being categorized as slow, or frail. In multivariable analysis, slower TUGT was a significant predictor of OAB (adjusted odds ratio: 3.0; 95% confidence interval: 2.0-4.8). Age was not independently associated with this diagnosis (P values >.05 for each age group).

CONCLUSION

Patients with OAB are statistically significantly frailer than individuals seeking care for other non-oncologic urologic diagnoses. Frailty, when adjusted for age, race, and gender, is a statistically significant predictor of OAB. Furthermore, frailty should be considered when caring for older patients with OAB, and OAB should be assessed when caring for frail older patients.

INTRODUCTION

Older patients frequently undergo operations that carry high risk for postoperative complications and death. Poor preoperative communication between patients and surgeons can lead to uninformed decisions and result in unexpected outcomes, conflict between surgeons and patients, and treatment inconsistent with patient preferences. This article describes the protocol for a multisite, cluster-randomised trial that uses a stepped wedge design to test a patient-driven question prompt list (QPL) intervention aimed to improve preoperative decision making and inform postoperative expectations.

METHODS AND ANALYSIS

This Patient-Centered Outcomes Research Institute-funded trial will be conducted at five academic medical centres in the USA. Study participants include surgeons who routinely perform vascular or oncological surgery, their patients and families. We aim to enrol 40 surgeons and 480 patients over 24 months. Patients age 65 or older who see a study-enrolled surgeon to discuss a vascular or oncological problem that could be treated with high-risk surgery will be enrolled at their clinic visit. Together with stakeholders, we developed a QPL intervention addressing preoperative communication needs of patients considering major surgery. Guided by the theories of self-determination and relational autonomy, this intervention is designed to increase patient activation. Patients will receive the QPL brochure and a letter from their surgeon encouraging its use. Using audio recordings of the outpatient surgical consultation, patient and family member questionnaires administered at three time points and retrospective chart review, we will compare the effectiveness of the QPL intervention to usual care with respect to the following primary outcomes: patient engagement in decision making, psychological well-being and post-treatment regret for patients and families, and interpersonal and intrapersonal conflict relating to treatment decisions and treatments received.

ETHICS AND DISSEMINATION

Approvals have been granted by the Institutional Review Board at the University of Wisconsin and at each participating site, and a Certificate of Confidentiality has been obtained. Results will be reported in peer-reviewed publications and presented at national meetings.

TRIAL REGISTRATION NUMBER

NCT02623335.

Importance

Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.

Objective

To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.

Design, Setting, and Participants

A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.

Main Outcomes and Measures

The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.

Results

A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001).

Conclusions and Relevance

Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.

BACKGROUND

Surgical quality datasets can be better tailored toward older adults. The American College of Surgeons (ACS) NSQIP Geriatric Surgery Pilot collected risk factors and outcomes in 4 geriatric-specific domains: cognition, decision-making, function, and mobility. This study evaluated the contributions of geriatric-specific factors to risk adjustment in modeling 30-day outcomes and geriatric-specific outcomes (postoperative delirium, new mobility aid use, functional decline, and pressure ulcers).

STUDY DESIGN

Using ACS NSQIP Geriatric Surgery Pilot data (January 2014 to December 2016), 7 geriatric-specific risk factors were evaluated for selection in 14 logistic models (morbidities/mortality) in general-vascular and orthopaedic surgery subgroups. Hierarchical models evaluated 4 geriatric-specific outcomes, adjusting for hospitals-level effects and including Bayesian-type shrinkage, to estimate hospital performance.

RESULTS

There were 36,399 older adults who underwent operations at 31 hospitals in the ACS NSQIP Geriatric Surgery Pilot. Geriatric-specific risk factors were selected in 10 of 14 models in both general-vascular and orthopaedic surgery subgroups. After risk adjustment, surrogate consent (odds ratio [OR] 1.5; 95% CI 1.3 to 1.8) and use of a mobility aid (OR 1.3; 95% CI 1.1 to 1.4) increased the risk for serious morbidity or mortality in the general-vascular cohort. Geriatric-specific factors were selected in all 4 geriatric-specific outcomes models. Rates of geriatric-specific outcomes were: postoperative delirium in 12.1% (n = 3,650), functional decline in 42.9% (n = 13,000), new mobility aid in 29.7% (n = 9,257), and new or worsened pressure ulcers in 1.7% (n = 527).

CONCLUSIONS

Geriatric-specific risk factors are important for patient-centered care and contribute to risk adjustment in modeling traditional and geriatric-specific outcomes. To provide optimal patient care for older adults, surgical datasets should collect measures that address cognition, decision-making, mobility, and function.