Frailty before surgery tied to more complications, higher costs

(Reuters Health) – Patients who are frail before surgery are more likely to have serious complications afterward and increased costs of care, suggesting that frailty should be factored into risk calculations before surgery, researchers say.

The study team assessed 14,530 patients for frailty before common non-emergency operations such as heart surgery, cancer operations, plastic surgery and organ transplants. Overall, 3.4 percent of the patients had high levels of frailty, based on signs like recent dramatic weight loss, poor grip strength, or other indications that their bodies might not be resilient to stress.

Compared to people with low or no frailty, patients with high frailty were almost three times more likely to experience major complications after outpatient surgery and almost twice as likely to have serious complications after inpatient surgery, the study found.

“Frailty is a state of increased vulnerability usually associated with aging and a decline in reserve such that the ability to cope with acute stressors is compromised,” said senior study author Dr. Claire Larson Isbell of Baylor Scott & White Medical Center in Temple, Texas.

“This means patients have a decreased physiologic reserve to recover from a traumatic event such as surgery,” Isbell said by email. “As a result, frail patients take longer to recover, and are more likely to suffer a higher rate of postoperative complications.”

Much of the previous research linking frailty to worse surgical outcomes has focused on elderly patients or other high-risk groups, researchers note in the Journal of the American College of Surgeons.

In the current study, however, some relatively young people in their 40s and 50s had high levels of frailty, Isbell said.

Half of the people who had inpatient surgery in the study were at least 61 years old, while the median age for outpatient surgery patients was 56.

Most patients were overweight or obese, and cancer was the most common diagnosis.

Even people with intermediate levels of frailty were 60 percent more likely to have serious complications after inpatient surgery and more than twice as likely to experience major complications after outpatient procedures, the study found.

After outpatient surgery, the frailest patients were also more than twice as likely as the least frail to be admitted to the emergency room.

High levels of frailty were also associated with more than doubled odds of repeat hospitalizations after inpatient surgery and more than five times the likelihood of being discharged to facilities like nursing homes or rehab centers instead of being sent home.

As a result, total costs for treating frail patients were higher than for non-frail patients by an average of $7,000 to $8,600.

The study wasn’t designed to prove whether or how frailty might directly cause complications or stall recovery after surgery.

Even so, the results add to evidence suggesting that evaluating patients before surgery and giving “prehabilitation” to increase their strength and functioning before operations might help prevent complications, said Dr. Bellal Joseph, chief of trauma critical care, burns and emergency surgery at the University of Arizona in Tucson.

“The new science that has entered our surgical world is prehabilitation – rehab prior to surgery,” Joseph, who wasn’t involved in the study, said by email.

“This simple intervention doesn’t mean heavy aggressive working out,” Joseph said. “Just improved diet, simple walking and exercises, and mindfulness exercises together have shown to get patients ready for the stress of surgery.”

SOURCE: Journal of the American College of Surgeons, online March 1, 2019.


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