Myrick C Shinall1, Shipra Arya2,3, Ada Youk4,5, Patrick Varley6, Rupen Shah7, Nader N Massarweh8,9, Paula K Shireman10,11, Jason M Johanning12,13, Alaina J Brown14, Neil A Christie15, Lawrence Crist15, Catherine M Curtin16, Brian C Drolet17, Rajeev Dhupar15, Jennifer Griffin18, James W Ibinson19, Jonas T Johnson20, Sonja Kinney18, Chad LaGrange21, Alexander Langerman22, Gary E Loyd23, Leila J Mady20, Michael P Mott24, Murali Patri25, Justin C Siebler26, C J Stimson27, William E Thorell28, Scott A Vincent26, Daniel E Hall4,6,29. 1. Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. 2. Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California. 3. Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California. 4. Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. 5. Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. 6. Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. 7. Department of Surgery, Henry Ford Health System, Detroit, Michigan. 8. Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. 9. Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. 10. Department of Surgery, University of Texas Health San Antonio, San Antonio. 11. South Texas Veterans Health Care System, San Antonio. 12. Department of Surgery, University of Nebraska Medical Center, Omaha. 13. Nebraska Western Iowa Veterans Affairs Health System, Omaha. 14. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee. 15. Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. 16. Department of Surgery, Stanford University, Palo Alto, California. 17. Deparment of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. 18. Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha. 19. Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. 20. Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania. 21. Division of Urology, University of Nebraska Medical Center, Omaha. 22. Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee. 23. Perioperative Surgical Home, Henry Ford Health System, Detroit, Michigan. 24. Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan. 25. Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan. 26. Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha. 27. Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee. 28. Department of Neurosurgery, University of Nebraska Medical Center, Omaha. 29. Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Abstract
Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood. Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study. Design, Setting, and Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress. Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score. Main Outcomes and Measures: Postoperative mortality at 30, 90, and 180 days. Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures. Conclusions and Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.
Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood. Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study. Design, Setting, and Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress. Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score. Main Outcomes and Measures: Postoperative mortality at 30, 90, and 180 days. Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures. Conclusions and Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.
Authors: Rupen Shah; Jeffrey D Borrebach; Jacob C Hodges; Patrick R Varley; Mary Kay Wisniewski; Myrick C Shinall; Shipra Arya; Jonas Johnson; Joel B Nelson; Ada Youk; Nader N Massarweh; Jason M Johanning; Daniel E Hall Journal: J Am Geriatr Soc Date: 2020-04-20 Impact factor: 5.562
Authors: Kathryn E Callahan; Clancy J Clark; Angela F Edwards; Timothy N Harwood; Jeff D Williamson; Adam W Moses; James J Willard; Joseph A Cristiano; Kellice Meadows; Justin Hurie; Kevin P High; J Wayne Meredith; Nicholas M Pajewski Journal: J Am Geriatr Soc Date: 2021-01-19 Impact factor: 5.562
Authors: Elizabeth L George; Nader N Massarweh; Ada Youk; Katherine M Reitz; Myrick C Shinall; Rui Chen; Amber W Trickey; Patrick R Varley; Jason Johanning; Paula K Shireman; Shipra Arya; Daniel E Hall Journal: JAMA Surg Date: 2022-03-01 Impact factor: 14.766
Authors: Katherine M Reitz; Daniel E Hall; Myrick C Shinall; Paula K Shireman; Jonathan C Silverstein Journal: J Surg Res Date: 2021-08-28 Impact factor: 2.192
Authors: Qi Yan; Jeongsoo Kim; Daniel E Hall; Myrick C Shinall; Katherine Moll Reitz; Karyn B Stitzenberg; Lillian S Kao; Elizabeth L George; Ada Youk; Chen-Pin Wang; Jonathan C Silverstein; Elmer V Bernstam; Paula K Shireman Journal: Ann Surg Date: 2021-06-25 Impact factor: 12.969