When patients are frail, they are more likely to experience postoperative complications or die after surgery.1

“There is no such thing as a minor operation for frail patients,” says Myrick Shinall, Jr., MD, PhD, assistant professor and general surgeon at Vanderbilt University Medical Center. “Even for procedures that we as surgeons think of as minor surgery, we need to think about and evaluate whether or not our patients are frail. If they are frail, we should include that piece of information in our shared decision-making with them.”

Shinall and colleagues measured frailty and surgery outcomes using the Risk Analysis Index and an operative stress score.1 “My colleagues have developed a tool to measure frailty that can be administered in person to folks as they are preparing for surgery,” Shinall explains.

For research purposes, frailty also can be determined using quality improvement records, such as data from the Veterans Affairs Surgical Quality Improvement Program, which is what Shinall and colleagues used for their study. “We were able to see the level of frailty of patients undergoing all sorts of noncardiac operations, including what we consider minor procedures on an outpatient basis,” Shinall says.

The study included 432,828 unique patients (92.8% were men; mean age = 61 years). Investigators identified 36,579 patients who were frail. The 30-day mortality rate among the frail patients, undergoing the lowest-stress surgical procedures (e.g., cystoscopy), was 1.55%.

For frail patients who underwent a moderate-stress surgical procedure, (e.g., laparoscopic cholecystectomy), the 30-day mortality rate was 5.13%. In both cases, the mortality rate exceeded the 1% mortality rate used to describe high-risk surgery. Operations were ranked from one (low risk) to five (major procedure).

“We looked at mortality of patients based on their frailty and level of operation they had,” Shinall says. “What we found is that even frail patients undergoing the lowest-stress operations ... had significant mortality within one month and six months after that operation.”

Shinall says surgeons may be seeing patients who are frail, but those patients may not be recognized as such. “We’re not factoring that into the decisions about whether they can withstand the stress of an operation or whether they have enough life expectancy to justify the expense and discomfort that comes with doing an operation,” he offers.

The study’s findings suggest surgeons should engage in nuanced discussions and shared decision-making with patients. Surgeons can talk to patients about how even a small operation could lead to death, Shinall suggests. “They can say, ‘We need to consider whether this operation is the right thing for you at this point,’” he adds.

The first step is to use a screening tool for frailty. Shinall refers again to the Risk Analysis Index.2 “Although we used the tool in a retrospective way, my co-authors have shown it’s easy to administer prospectively when making decisions about whether to operate on them or not,” he says. “We need to think about screening people, and not just for big operations but for minor outpatient procedures as well. With screening for frailty, we can make better decisions with our patients.”

The screening can be handled over the phone. “The tool’s calibration for predicting mortality is very good,” Shinall adds. “The other nice thing about it is that in addition to quantifying risk, it gives you an idea of where the risk is coming from, whether it’s the patient’s nutrition, comorbidity, or whatever.”

If a patient scores high on frailty screening, then clinicians can act accordingly. “As a clinician, the screening tool can give you a feeling that if the patient would benefit from this operation, there are things you can do to lower their risk,” Shinall says. For example, if the screening tool suggests the patient is malnourished, then the surgeon could suggest the patient meet with a nutritionist or take supplements before the procedure. If mobility is a problem, the patient could see a physical therapist and perform exercises to become stronger.

“A lot of it comes down to good, old-fashioned, patient-doctor communication,” Shinall says. “I think the big thing is being open and honest with the patient about what you know about their risks. I would frame it this way: ‘As a surgeon, this is something I am very worried about for you. Because of these issues, you are at higher risk for this surgery.’”

If there is no way to lower the patient’s risk, then the clinician can say, “If you want to go through with this operation, we want you to go through it knowing this is a risk and to make sure it’s an operation that fits with your goals.”

REFERENCES

  1. Shinall MC, Arya S, Youk A, et al. Association of preoperative patient frailty and operative stress with postoperative mortality. JAMA Surg 2019;155:e194620.
  2. Hall DE, Arya S, Schmid KK, et al. Development and initial validation of the Risk Analysis Index for measuring frailty in surgical populations. JAMA Surg 2017;152:175-182.