Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery

Rupen Shah, Kristopher Attwood, Shipra Arya, Daniel E. Hall, Jason M Johanning, Emmanuel Gabriel, Anthony Visioni, Steven Nurkin, Moshim Kukar, Steven Hochwald, Nader N. Massarweh

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Abstract

IMPORTANCE Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. OBJECTIVE To assess the association of frailty with FTR in patients undergoing inpatient surgery. DESIGN, SETTING, AND PARTICIPANTS This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score,≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. MAIN OUTCOMES AND MEASURES The number of postoperative complications and inpatient FTR. RESULTS A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5%for those with scores of 10 or less, 23.7%for those with scores of 11 to 20, 31.1%for those with scores of 21 to 30, 42.5%for those with scores of 31 to 40, and 54.4%for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95%CI, 3.9-7.1). Odds ratios were 8.1 (95%CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95%CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95%CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95%CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95%CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95%CI, 8.1-9.9; vs RAI score >40: 18.4; 95%CI, 15.7-21.4). CONCLUSIONS AND RELEVANCE Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.

Original languageEnglish (US)
Article numbere180214
JournalJAMA Surgery
Volume153
Issue number5
DOIs
StatePublished - May 2018

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Inpatients
Odds Ratio
Thoracic Surgery
Mortality

ASJC Scopus subject areas

  • Surgery

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Shah, R., Attwood, K., Arya, S., Hall, D. E., Johanning, J. M., Gabriel, E., ... Massarweh, N. N. (2018). Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery. JAMA Surgery, 153(5), [e180214]. https://doi.org/10.1001/jamasurg.2018.0214

Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery. / Shah, Rupen; Attwood, Kristopher; Arya, Shipra; Hall, Daniel E.; Johanning, Jason M; Gabriel, Emmanuel; Visioni, Anthony; Nurkin, Steven; Kukar, Moshim; Hochwald, Steven; Massarweh, Nader N.

In: JAMA Surgery, Vol. 153, No. 5, e180214, 05.2018.

Research output: Contribution to journalArticle

Shah, R, Attwood, K, Arya, S, Hall, DE, Johanning, JM, Gabriel, E, Visioni, A, Nurkin, S, Kukar, M, Hochwald, S & Massarweh, NN 2018, 'Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery', JAMA Surgery, vol. 153, no. 5, e180214. https://doi.org/10.1001/jamasurg.2018.0214
Shah, Rupen ; Attwood, Kristopher ; Arya, Shipra ; Hall, Daniel E. ; Johanning, Jason M ; Gabriel, Emmanuel ; Visioni, Anthony ; Nurkin, Steven ; Kukar, Moshim ; Hochwald, Steven ; Massarweh, Nader N. / Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery. In: JAMA Surgery. 2018 ; Vol. 153, No. 5.
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title = "Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery",
abstract = "IMPORTANCE Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. OBJECTIVE To assess the association of frailty with FTR in patients undergoing inpatient surgery. DESIGN, SETTING, AND PARTICIPANTS This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score,≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1{\%}) or high mortality risk (>1{\%}). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. MAIN OUTCOMES AND MEASURES The number of postoperative complications and inpatient FTR. RESULTS A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8{\%}) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2{\%}; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6{\%}, 13.5{\%}, 23.8{\%}, and 36.4{\%}, respectively. After high-risk surgery, these rates were 13.5{\%}for those with scores of 10 or less, 23.7{\%}for those with scores of 11 to 20, 31.1{\%}for those with scores of 21 to 30, 42.5{\%}for those with scores of 31 to 40, and 54.4{\%}for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95{\%}CI, 3.9-7.1). Odds ratios were 8.1 (95{\%}CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95{\%}CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95{\%}CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95{\%}CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95{\%}CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95{\%}CI, 8.1-9.9; vs RAI score >40: 18.4; 95{\%}CI, 15.7-21.4). CONCLUSIONS AND RELEVANCE Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.",
author = "Rupen Shah and Kristopher Attwood and Shipra Arya and Hall, {Daniel E.} and Johanning, {Jason M} and Emmanuel Gabriel and Anthony Visioni and Steven Nurkin and Moshim Kukar and Steven Hochwald and Massarweh, {Nader N.}",
year = "2018",
month = "5",
doi = "10.1001/jamasurg.2018.0214",
language = "English (US)",
volume = "153",
journal = "JAMA Surgery",
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TY - JOUR

T1 - Association of frailty with failure to rescue after low-risk and high-risk inpatient surgery

AU - Shah, Rupen

AU - Attwood, Kristopher

AU - Arya, Shipra

AU - Hall, Daniel E.

AU - Johanning, Jason M

AU - Gabriel, Emmanuel

AU - Visioni, Anthony

AU - Nurkin, Steven

AU - Kukar, Moshim

AU - Hochwald, Steven

AU - Massarweh, Nader N.

PY - 2018/5

Y1 - 2018/5

N2 - IMPORTANCE Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. OBJECTIVE To assess the association of frailty with FTR in patients undergoing inpatient surgery. DESIGN, SETTING, AND PARTICIPANTS This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score,≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. MAIN OUTCOMES AND MEASURES The number of postoperative complications and inpatient FTR. RESULTS A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5%for those with scores of 10 or less, 23.7%for those with scores of 11 to 20, 31.1%for those with scores of 21 to 30, 42.5%for those with scores of 31 to 40, and 54.4%for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95%CI, 3.9-7.1). Odds ratios were 8.1 (95%CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95%CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95%CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95%CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95%CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95%CI, 8.1-9.9; vs RAI score >40: 18.4; 95%CI, 15.7-21.4). CONCLUSIONS AND RELEVANCE Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.

AB - IMPORTANCE Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. OBJECTIVE To assess the association of frailty with FTR in patients undergoing inpatient surgery. DESIGN, SETTING, AND PARTICIPANTS This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score,≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. MAIN OUTCOMES AND MEASURES The number of postoperative complications and inpatient FTR. RESULTS A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5%for those with scores of 10 or less, 23.7%for those with scores of 11 to 20, 31.1%for those with scores of 21 to 30, 42.5%for those with scores of 31 to 40, and 54.4%for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95%CI, 3.9-7.1). Odds ratios were 8.1 (95%CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95%CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95%CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95%CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95%CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95%CI, 8.1-9.9; vs RAI score >40: 18.4; 95%CI, 15.7-21.4). CONCLUSIONS AND RELEVANCE Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.

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