Kim SW, Han HS, Jung HW, et al.
JAMA Surg 2014;149:633-40
Publication date: July 1, 2014
Summary
The number of older patients who undergo surgery is increasing, and these patients often have comorbid conditions that may lead to postoperative mortality and morbidity. Therefore, it is important to identify at-risk patients. Yet, there are insufficient tools to predict postoperative outcomes in older patients.
The authors performed a single-center prospective cohort study aimed to develop a scoring model to predict unfavorable outcomes and prolonged hospital stays quantitatively after surgery. A comprehensive geriatric assessment (CGA) was performed in 275 consecutive patients aged 65 years or older undergoing intermediate- or high-risk elective operations at the Seoul National University Bundang Hospital, South Korea. The primary outcome measure was 1-year all-cause mortality. Secondary outcomes were postoperative complications, length of hospital stay, and discharge to a nursing facility.
Twenty-five patients (9.1%) died during the follow-up period, including 4 during their hospital stay. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Based on CGA data, the authors developed a new multidimensional frailty score comprising malignant disease, Charlson Comorbidity Index, serum albumin, activities of daily living (modified Barthel Index), instrumental activities of daily living (Lawton and Brody Index, dementia, risk of delirium, nutritional status (Mini Nutritional Assessment) and midarm circumference. This model predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification. The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model’s cutoff point. High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = 0.003) and longer hospital stays after surgery (median [interquartile range], 9 [5-15] vs. 6 [3-9] days; P < 0.001).
The authors found that a multidimensional frailty model based on CGA is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery. This model should therefore help physicians distinguish the truly high-risk patients from the fit older patients at low risk of postoperative complications.