Patrick R Varley1, Jeffrey D Borrebach2, Shipra Arya3, Nader N Massarweh4, Andrew L Bilderback2, Mary Kay Wisniewski2, Joel B Nelson5, Jonas T Johnson6, Jason M Johanning7, Daniel E Hall1,2,8. 1. Department of Surgery, University of Pittsburgh, Pittsburgh, PA. 2. Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA. 3. Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Surgical Service Line VA Palo Alto Healthcare System, Palo Alto, CA. 4. Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX; Division of Surgical Oncology, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX. 5. Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA. 6. Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA. 7. Department of Surgery, University of Nebraska Medical Center, Omaha, NE; Nebraska Western Iowa VA Health System, Omaha, NE. 8. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.
Abstract
OBJECTIVE: The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently demonstrate its utility for identifying at-risk surgical patients. BACKGROUND: Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice. METHODS: Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed. RESULTS: RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 [IQR 23-53] seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 [95% C.I.: 1.091 - 1.106], p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively. CONCLUSIONS: The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.
OBJECTIVE: The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently demonstrate its utility for identifying at-risk surgical patients. BACKGROUND: Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice. METHODS: Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed. RESULTS: RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 [IQR 23-53] seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 [95% C.I.: 1.091 - 1.106], p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively. CONCLUSIONS: The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.
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; Patrick R Varley; Nathan L Liang; Ada Youk; Elizabeth L George; Myrick C Shinall; Paula K Shireman; Shipra Arya; Edith Tzeng; Daniel E Hall Journal: Ann Surg Date: 2021-10-01 Impact factor: 13.787
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
Authors: Myrick C Shinall; Ada Youk; Nader N Massarweh; Paula K Shireman; Shipra Arya; Elizabeth L George; Daniel E Hall Journal: JAMA Netw Open Date: 2020-07-01