20 Jan Frail Patients Much More Likely To Die After Surgery
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MedicalResearch.com Interview with:
Dr. Daniel I McIsaac, MD, MPH, FRCPC
Assistant Professor of Anesthesiology
Department of Anesthesiology
The Ottawa Hospital, Civic Campus
Medical Research: What is the background for this study?
Dr. McIsaac: Older age is a well-known risk factor for adverse outcomes after surgery, however, many older patients have positive surgical outcomes. Frailty is a syndrome that encompasses the negative health attributes and comorbidities that accumulate across the lifespan, and is a strong discriminating factor between high- and low-risk older surgical patients. By definition, frail patients are “sicker” than non-frail patients, so their higher rates of morbidity and mortality after surgery aren’t surprising. However, frailty increases in prevalence with increasing age, so as our population ages we expect to see more frail people presenting for surgery. Our goal was to evaluate the impact of frailty on postoperative mortality at a population-level, and over the first year after surgery to provide insights that aren’t available in the current literature, which largely consists of single center studies limited to in-hospital and 30-day outcome windows.
Medical Research: What are the main findings?
Dr. McIsaac: Our main finding was that the daily risk-adjusted rate of mortality was significantly higher (10-30 times) in the first week after surgery for frail patients than for non-frail patients, before leveling off to a steady 2 times higher rate two to three months after surgery. This supports one of the primary hypotheses about why frailty is an important risk factor for postoperative mortality. By definition, frail people have decreased physiologic reserve, and surgery creates a substantial physiologic stress. Frail patients appear to tolerate this stress poorly.
A second important finding was the impact of frailty on mortality across different surgical procedures. On a relative basis, frail patients were far more likely to die after total joint replacement than after intraabdominal surgery. Total joint replacements were the most common surgeries in frail elderly patients, by far, which suggests that the perioperative care of frail patients presenting for major orthopedic surgery needs to be an area of focus moving forward.
Medical Research: What should clinicians and patients take away from your report?
Dr. McIsaac: Our findings that early postoperative mortality is much higher in frail patients suggests that surgical stress is poorly tolerated by frail patients, and identifies the early postoperative period as a key area for enhancing clinical care and for future research aimed at improving the outcomes of frail patients. Perioperative care for total joint replacement appears to be a priority area in this regard.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. McIsaac: There is a significant amount of research that needs to be done moving forward. To date, most research has focused on identifying frailty as a risk-factor; we are now at the point where it is time to start addressing the specific risk profile of frail patients and intervening to improve outcomes. The early postoperative mortality risk that we have identified suggests that we need to look at the early postoperative period and define why frail patients are dying early. Is this a failure to rescue phenomenon, or is something else at play? We also need to start identifying frail patients before surgery in the clinical setting to provide an opportunity to optimize patients’ physical and mental status, as well as to optimize the health care system to address their needs. High-quality prospective research will be needed to address these issues.
Dr. Daniel I McIsaac, MD, MPH, FRCPC (2016). Frail Patients Much More Likely To Die After Surgery