The issue of medical frailty

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With people aged 65 and over making up the fastest growing segment of the US population, medical frailty – and its attendant increase in perioperative morbidity and mortality – is a pressing topic for the vascular community.

Dr. Yazan Duwayri is investigating long-term effects of frailty on vascular interventions using the Vascular Quality Initiative. He envisions a day when such research leads to a vascular surgery frailty index.

Dr. Duwayri is assistant professor of surgery, division of vascular surgery and endovascular therapy, at Emory University School of Medicine, and an author of the 2014 Vascular Annual Meeting poster presentation, “Frailty Increases Risk of Mortality After Elective Abdominal Aortic Aneurysm Repair Independent of Age and Comorbidity Status.”

Why is medical frailty rising to prominence?

Dr. Yazan Duwayri

The utilization of surgical and medical services is disproportionately increasing in specialties like ours because of the aging population. Value-based models in health care are developing because of cost constraints, and to improve the quality of delivered health care.

Length of stay, failed discharges, and post-hospitalization institutionalization are important metrics in these models. Chronological age by itself has not been a consistent predictor of postoperative events. Similarly, various health traits have had inconsistent effects of small significance.

The need to aggregate these factors together into one single measure, frailty, has therefore risen to prominence.

Could you summarize the most significant research over the past three years on this topic?

Quantifying frailty and the development of frailty measurement tools dominated research in the earlier period. Over the last three years, there were several hundred publications on the topic of frailty. A significant portion of this research has focused on the impact of frailty scores on patient outcomes in varying disease processes and with different treatment modalities.

In the surgical literature, frailty was evaluated as a preoperative risk assessment measure and as a predictor of longevity. Frailty was found to be a predictor of short- and mid-term mortality after elective cardiac surgery and proximal aortic surgery independent of age. Similarly, there was a significant association between a higher preoperative frailty index and increased morbidity and mortality in thoracic surgery patients.

In general surgery patients, frailty has been shown to increase risk of complications, mortality, prolonged hospital stay and postoperative institutionalization.

A study of vascular surgery patients in ACS NSQIP also showed that the frailest patients have higher mortality and wound complication rates. Similarly, when core muscles size was used as a measure of frailty, it was found to correlate with worse outcomes after open abdominal aortic repairs.

Where are the gaps in knowledge?

The elderly constitute a significant portion of the population treated by vascular surgeons. Despite that, research on the effect of frailty on postoperative outcomes in our field has been limited thus far. Also, we need better understanding of the role of prehabilitation before interventions on frail patients, and whether or not it can improve outcomes.

Similarly, we need to pursue further research on longevity prediction using frailty, which can help guide vascular surgeons in the choice of therapies of asymptomatic pathologies such as aortic aneurysms and carotid artery disease. On a preclinical level, further research on the pathophysiology of frailty in vascular surgery patients is needed.

How are you using the Vascular Quality Initiative to address this issue?

The Vascular Quality Initiative has allowed us to prospectively collect a large number of variables on various vascular surgical procedures at different levels of complexity.

The large number of preoperative variables collected can allow for the development of a vascular surgery frailty index. Since VQI tracks outcomes longer than any other database, we are able to identify the long-term effects of frailty on our interventions.

Since medical frailty is multifactorial, how does this affect your model for patient care?

We have not yet implemented a preoperative method of quantifying frailty into our clinical practice.

However, we recognize the value of “accumulated deficits” and the burden of senescence in our patients during the preoperative interactions. This allows us to better estimate the risks and benefits of surgical therapy, and to set more realistic patient expectations.

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