PITTSBURGH _ As the population ages, more and more older people are seeking elective surgeries to replace their hips and knees, to repair their backs and to fix other problems.
And doctors who treat elderly patients are well aware of how their levels of strength or frailty can affect the outcomes of these surgeries and their quality of life.
So applying assessments of frailty in people planning to have surgery may lead to better health outcomes afterward, according to new research led by Pittsburgh surgeon and researcher Daniel E. Hall.
Hall, of the Veterans Affairs Pittsburgh Healthcare System and the University of Pittsburgh, compared results of no frailty screening with those of screening involving patients who had surgery at the VA medical center in Omaha, Neb. The study was published Wednesday by JAMA Surgery.
In the study of 9,153 patients _ average age 60 _ screening was linked to decreased patient deaths, from a rate of 1.6 percent to 0.7 percent at the point of 30 days after surgery. Among those considered frail beforehand, the rate of deaths went from 12.2 percent (24 of 197 patients) down to 3.8 percent (16 out of 424 patients), with the use of the frailty screening.
Each patient's frailty was assessed with the Risk Analysis Index, based on 14 questions related to the patient's living arrangement and daily activity and medical, nutrition and cognitive conditions.
Screening results were used to prompt of review of the patient's case by the chief of surgery or his or her representative and that review was shared with a team of clinicians from surgery, anesthesia, critical care and palliative care, who then considered the patient's frailty and risks. That team could modify plans for the patient before, during and after the operation.
Frailty screening and the clinicians' involvement is already part of the elective surgery process at UPMC hospitals and Allegheny General Hospital, according to health professionals in both health care systems.
Hall said the study represents the first attempt to look at frailty in a systemized way. It's a step beyond "the eyeball test," which surgeons traditionally use to assess whether a patient can endure surgery.
"Surgeons have good eyeballs," Hall said, but he added that the frailty assessment can be used to improve the patient's surgical outcome in a new way.
"This puts the emphasis on functionality. ... This is first example of screening an entire health system ... and doing something about it."
The advantages of screening and modifications for individual frail patients paid off even more at six months and a year afterward, according to the study. At 180 days, mortality was reduced from 23.9 percent to 7.7 percent; at 365 days, the rate went down from 34.5 percent to 11.7 percent.
Even so-called robust patients saw reductions in mortality, but Hall said that was less pronounced (a rate of 1.2 percent lowered to 0.3 percent), and may be attributed to the beneficial effect of being part of a care-improvement effort.
The screening takes 1 to 2 minutes. It allows doctors to think carefully about the best way to approach the surgery (at UPMC they call it the "surgical pause").
"It's not a way of rationing health care; it's just a way to identify people who are at risk ... are there outcomes that are unacceptable?" he said.
For example, patients can be identified as frail if they have trouble getting out of a chair and walking across a room and turning around and returning to the chair. Problems with balance and coordination may mean a person who is frail doesn't have physiological reserves that will enable them to recover well from surgery, Hall said.
"General anesthesia and a two-hour operation have been compared to running a 5K race. But if (a patient) is not ready, there are things we can do to get them ready."
Mary Kay Wisniewski, improvement specialist at the Donald D. Wolff Jr. Center for Quality, Safety, and Innovation of UPMC, said better outcomes for frail patients is part of the overall patient safety effort. She said all UPMC surgeons in its 23 hospitals now use the screening.
"Dr. Hall's risk assessment tool fit into what we want to accomplish," she said.
Getting a patient prepared for surgery can include healthy eating and weight management, adding physical activity, breathing exercises, pain management, help with quitting smoking and supportive care services. A patient sets goals for what he or she hopes to achieve through surgery.
