What if there was a test you could do on patients in under a minute that would tell you which of them were most likely to have post-surgical complications? According to a study out of Emory University in Atlanta scheduled for publication later this year in the Journal of the American College of Surgeons,1 looking at just two or three simple metrics can readily identify such patients, giving you a way to manage outcomes expectations, work to reduce risks post-surgically, or potentially improve the risk profile of the patient before surgery if there is time.
The study by Viraj Master, MD, PhD, associate professor of urology and the quality director of the clinical research unit at the university, and his colleagues, looked at 351 patients scheduled for abdominal surgery. Patients were monitored for shrinking — unintentional weight loss of 10 pounds or more during the last year — and grip strength, along with serum hemoglobin values. Previous modes of determining frailty also included gait speed, activity levels, and exhaustion levels.
The authors looked at 30-day complication rates for participants, which included discharge to a nursing home, and found that those with weak grip and evidence of shrinking alone were more likely to suffer complications. Those two criteria were just as effective at predicting complications as the five-metric previous frailty tests, according to the study. If you add in the blood work data, the authors found they were able to create a stratification of risk for patients.
“You get the best possible information, with the most bang for the buck with weight loss, grip strength, and hemoglobin,” says Master. “But even without the hemoglobin tests, you can still get a pretty good idea of who is frail and who is not.”
Co-author Kenneth Ogan, MD, an associate professor of urology at Emory, says knowing who is frail and who isn’t is something he believes should be another vital sign for all patients. “Eventually, I think we should get the heart rate, the blood pressure, and then ask everyone about their weight loss and see how they do with grip strength. You get a great deal of information in a short amount of time — and we get less and less time with our patients these days.”
Patients who are extremely frail are increasingly the subject of study, says Master. While data is thin now, he thinks that in the future it will be proved that frail patients spend longer in the hospital, are more likely to be readmitted, and tend to be discharged not to their homes, but to skilled nursing facilities or rehabilitation hospitals. “Those places have a huge implication on how you marshal your inpatient resources and services in the world of accountable care,” Master says.
Ogan says knowing who is frail also helps you manage the expectations of the patient and the family. “If they test frail, you can give them a much more accurate picture of what to expect out of surgery — more likely complications, a higher likelihood of discharge to a nursing home or rehab hospital. Our data will eventually show they probably have a higher risk of mortality, too. So patients and families will decide not to do a surgery, that it isn’t for them.”
It’s possible, too, that they will try to find a way to “pre-hab” themselves before surgery, Ogan says: beef up their health so that they are less likely to suffer those complications. The data hasn’t been collected yet on what kinds of work a patient could do to improve the odds of a complication-free surgery, but Ogan and Master are doing a trial right now where patients are given pedometers pre-surgically and told to walk 10,000 steps every day. The theory is that if they get healthier before surgery, they will do better after.
The problem is that there isn’t any clear knowledge yet whether the grip strength and shrinking metrics are markers for something specific, Master says. In other words, if you have a patient put back on some weight and work to improve grip strength, will the patient then go on to do well in surgery? Or is there something else going on that those two data points are indicators of that has yet to be identified? While Master says a lot of people are working on the issue of frailty, no one has figured out anything that deep yet.
“What’s important right now is to know that frail people do worse, that we should reset expectations for them and their family, that we should care for them differently post-surgically, and that we need to investigate whether there is a way to make them healthier before surgery in order to mitigate risk,” Ogan says.
Master says he would like to see every hospital, starting now, treat these two signs of frailty as elements of a vital sign, and ask every patient about them. “Then analyze this data,” he says. “We have hundreds of patients in our cohort, but we would like to know what it looks like for thousands.”
“Maybe it won’t signify the same thing on all services,” Ogan notes. “But when you have data on who the frail patients are, you can analyze their outcomes, and see if there are ways you can improve them on the front end, before they enter the hospital, or the back end, before they leave.”
“This is important information,” Master says. “Frailty should be on the tip of the quality tongue.”
For more information, contact:
- Viraj Master MD, PhD FACS, Associate Professor, Associate Chair for Clinical Affairs and Quality Director of Clinical Research Unit, Department of Urology, Emory University, Atlanta, GA. Email: firstname.lastname@example.org.
- Kenneth Ogan, MD, Associate Professor of Urology, Emory University, Atlanta, GA. Email: email@example.com.
- Revenig LM, Canter DJ, Kim S, Liu Y, Sweeney JF, Sarmiento JM, Kooby, DA, Maithel SK, Master VA, Ogan K, Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality, Journal of the American College of Surgeons (2015), doi:10.1016/j.jamcollsurg.2015.01.053.