The impact of frailty on the economic evaluation of geriatric surgery

The impact of frailty on the economic evaluation of geriatric surgery: hospital costs and opportunity costs based on meta-analysis.
J Med Econ. 2020;23(8):819-830. doi:10.1080/13696998.2020.1764965

• Two systematic reviews and meta-analysis to analyze the difference in costs between surgery for frail and non-frail elderly patients concluded that frail surgical geriatric patients generate a higher total hospital cost, and an opportunity cost arising from not operating in the best possible state of health. Preoperatively treating the frailty of elderly patients will improve the use of health resources.

Abstract

Robotic Surgery in the Frail Elderly: Analysis of Perioperative Outcomes

Robotic Surgery in the Frail Elderly: Analysis of Perioperative Outcomes
Ann Surg Oncol 23 Apr 2020 doi: 10.1245/s10434-020-08475-w.

• Analysis of 982 patients (71 frail and 911 non-frail patients) from Memorial Sloan Kettering Cancer Center, New York, who underwent a robotic surgical procedure May 2007 - December 2016 confirms other research findings that the frail elderly have longer hospital stays and more complications after surgery than the general population.

Abstract

The prevalence of frailty in patients on hemodialysis

The prevalence of frailty in patients on hemodialysis: a systematic review and meta-analysis.

Int Urol Nephrol. 2020 Jan;52(1):115-120. doi: 10.1007/s11255-019-02310-2

• A review of the evidence concludes that frailty influences almost three in ten patients on hemodialysis. 

Abstract

Frailty in lung transplantation: a systematic review

Frailty in lung transplantation: a systematic review
Expert Review of Respiratory Medicine, 19 December 2020, 14:2, 219-27, DOI: 10.1080/17476348.2020.1702527

• This article reviews the current literature on frailty in lung transplantation, with an emphasis on frailty measures, prevalence and impact of frailty on morbidity and mortality prior to and following lung transplantation. It concludes that frailty is identified often in lung transplant candidates and is associated with adverse pre and post-transplantation outcomes. Further research is necessary to identify potential frailty interventions.

Abstract

The prevalence of frailty in patients on hemodialysis: a systematic review and meta-analysis.

The prevalence of frailty in patients on hemodialysis: a systematic review and meta-analysis.
Int Urol Nephrol. 2019 Oct 23. doi: 10.1007/s11255-019-02310-2.

• Analysis of data from the international literature concludes that prevalence frailty influences almost three in ten patients on haemodialysis. There were no significant relationships between frailty in haemodialysis and factors such as country (Europe & USA vs Asia) or duration of haemodialysis.

Abstract

Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis.

Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis.
Am J Surg. 2019 Aug;218(2):393-400

• Meta-analysis of 16 RCTs (n=683,487 patients, 444,885 frail) to understand the association between modified Frailty Index and post-operative complications, re-admission, re-operation, discharge to a skilled care facility, and mortality.
• Frail patients (modified Frailty Index) were more likely to experience complications, major complications and wound complications. Furthermore, frail patients had higher risk of readmission and discharge to skilled care. Notably, the risk of mortality was 4.19 times more likely in frail patients.

Abstract

Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient.

Frailty Cost: Economic Impact of Frailty in the Elective Surgical Patient.
J Am Coll Surg. 2019 Jun;228(6):861-870

• A validated frailty index derived from a database of elective surgery at a US academic medical centre (n=10,257, years 2016-2017) found that frailty continued to be associated with increased direct cost, indirect cost, total cost, and decreased hospital income.

Abstract

Scoping review of frailty in vascular surgery.

Scoping review of frailty in vascular surgery.
J Vasc Surg. 24 Dec 2018 Dec 24. pii: S0741-5214(18)32465-0. doi: 10.1016/j.jvs.2018.10.053.

• Discussion of the variety of tools available to measure frailty in patients undergoing vascular surgery interventions

Abstract

Intensive care: balancing risk and benefit to facilitate informed decisions

Intensive care: balancing risk and benefit to facilitate informed decisions
BMJ 2018;363:k4135, 19 October 2018 doi: https://doi.org/10.1136/bmj.k4135

• Intensive care can be associated with substantial physical and psychosocial burdens for patients and may have adverse psychological consequences for families. Potential harms of intensive care are commonly overlooked in times of crisis when timely decisions need to be made about escalation of care. Frail, elderly patients have poorer outcomes after a stay in an intensive care unit (ICU) and are rarely consulted about their wishes for life sustaining treatments. 
• The decision to admit a patient to the ICU should include assessment of whether the likely benefits outweigh the risks. Where possible, patients and their families should be involved in the decision making process. Earlier information about intensive care practices and outcomes may help patients make informed choices about their future care.

Frailty indexes in perioperative and critical care: A systematic review.

Frailty indexes in perioperative and critical care: A systematic review.
Arch Gerontol Geriatr. 2018 Aug 19;79:88-96.

• Analysis of nine prospective and four retrospective cohort studies (enrolling 2539 patients) which utilised a frailty index consisting of ≥30 health deficits concludes that frail patients are at significantly increased risk in critical illness and the perioperative period.

Abstract

Frailty and Clinical Outcomes in Heart Failure: A Systematic Review and Meta-analysis.

Frailty and Clinical Outcomes in Heart Failure: A Systematic Review and Meta-analysis.

J Am Med Dir Assoc. 2018 Jul 31. pii: S1525-8610(18)30329-3.

• Frailty is a significant predictor of all-cause mortality and hospital readmissions in HF. Assessment and close monitoring of frailty status of heart failure patients can potentially better guide clinical management of this population.

Abstract

The incremental predictive value of frailty measures in elderly patients undergoing cardiac surgery: A systematic review.

The incremental predictive value of frailty measures in elderly patients undergoing cardiac surgery: A systematic review.
Clin Cardiol. 5 Jul 2018,  doi: 10.1002/clc.23021

• Analysis of 12 studies concludes that addition of frailty measures to existing preioperative risk models improved the prediction performance for mortality, but the incorporation of frailty assessment into the perioperative risk assessment needs further evidence before making health policy recommendations.

Abstract

Advancing Care, Advancing Years: Treating and Caring for an Ageing Population

Advancing Care, Advancing Years: Treating and Caring for an Ageing Population
Health Services Management Centre (Birmingham), ICF International, 26 June 2018

• This report examines the specific needs of older patients with cancer, and explores the process of clinical decision-making for older people with cancer across the UK.
• It discusses why older people’s needs not being identified or sufficiently well-understood, issues with the knowledge and awareness of the cancer workforce about the specific challenges of treating older patients, and lack of evidence to support new cancer treatments in older populations.
• The research involved a literature review, clinical observations at eight case study sites, interviews with 15 national decision-makers and 80 health professionals, and three UK-wide surveys (of primary care professionals, secondary care professionals and older people affected by cancer). The direction of the research was also informed by engagement with a group of older people affected by cancer, and by extensive engagement and interviews with national policymakers. 

Can Charlson Co-Morbidity Index Predict ICU Survival?

Can Charlson Co-Morbidity Index Predict ICU Survival?
Journal of the Intensive Care Society 2018, Vol. 19(2) Supplement 1–162, Abstract EP.060

• In a study of 64 patients aged over 50 years admitted for more than 24 hours to ICU in a DGH (Warrington and Halton Foundation Trust, Warrington, UK), Apache II score and Charlson Co-Morbidity Index appear to be predictive of survival

Abstract

Outcomes in critically ill octogenarians and older: A clinically relevant tool to inform admission decision making

Outcomes in critically ill octogenarians and older: A clinically relevant tool to inform admission decision making
Journal of the Intensive Care Society 2018, Vol. 19(2) Supplement 1–162, Abstract EP.83
Analysis of 705 emergency elderly admissions to ICU (Aintree University Hospital NHS Foundation Trust, Liverpool, UK) found that APACHE II score was a fair predictor of hospital mortality but a poor predictor of one year mortality.

Abstract

Recommendations for Preoperative Management of Frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

Recommendations for Preoperative Management of Frailty fromthe Society for Perioperative Assessment and Quality Improvement (SPAQI).
J Clin Anesth. 2018 June 15;47:33-42. doi: 10.1016/j.jclinane.2018.02.011.

• Practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. The recommendations summarise evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.

Hospital Frailty Risk Score focusing on older people in acute care settings

Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study.
Lancet. 2018 May 5;391(10132):1775-1782.

• A Hospital Frailty Risk Score for older people in acute care, based on routinely collected data, was found to be a low-cost systematic way of screening for frailty. Patients with the highest scores had increased odds of 30-day mortality, long hospital stay, and 30-day readmission.

Frailty in Hospitalized Older Adults: Comparing Different Frailty Measures

Frailty in hospitalized older adults: comparing different frailty measures in predicting short- and long-term patient outcomes. [Abstract]
J Am Med Dir Assoc. 2018 May;19(5):450-457.e3. doi: 10.1016/j.jamda.2017.10.006.

• A study to understand if the SOFA frailty rating scale to predict hospital mortality among elderly critically ill patients could be improved by combination with Clinical Frailty Scale (SOFA-CFS) concluded that the combination did not improve performance of the SOFA score alone. 
• Study details: French prospective observational study performed between February 2015 and February 2016 including 189 patients aged ≥65 years and hospitalized ≥24 h in the intensive care unit.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.
Am J Surg. 2018 Apr 18. pii: DOI: https://doi.org/10.1016/j.amjsurg.2018.04.006

• A review of studies of risk assessment tools in elderly surgical patients suggests that NSQIP-PMP, mFI and SURPAS are promising tools.

Abstract

Frailty as a risk predictor in cardiac surgery

Frailty as a risk predictor in cardiac surgery: Beyond the eyeball test
J Thorac Cardiovasc Surg. 2018 Mar 11. pii: S0022-5223(18)30704-9.

•  The identification of preoperative frailty improves risk prediction and provides targets for optimization for enhanced recovery after cardiac surgery. A frailty outcome modifier in cardiac surgery is described.
• Contents
• I.What is Frailty and is it a Risk Predictor in Cardiac Surgery?
• II.How do we Measure Frailty?
• III.Can Frailty Assessment Help to Determine Whether there is a Net Clinical Benefit of Surgery?
• IV.How can Risk Scores Incorporate Frailty Measures?
• V.Can we “Defrail” the Older Adult Cardiac Surgery Patient?
• VI.Interdisciplinary Team
• VII.An Economic Argument
• VIII.Conclusion