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JAMA Surgery Highlights Study Findings that Show No ‘Low-Risk Surgeries’ in High-Risk, Frail Patients

March 27, 2020

Takeaway: Even minor operations are high-risk for frail patients. Given the impact of frailty across all types of surgery, routine frailty screening is imperative. This Diffusion of Excellence Gold Status Project is scaling up a highly effective clinical tool to screen frail elderly Veterans before they have surgery.

Surgical stress can exhaust frail patients’ limited reserve, leading to catastrophic decompensation, loss of independence, and even death. However, there is an inadequate understanding of whether frailty’s association with poor outcomes varies with the physiologic stress of operation. Many surgical procedures are considered so minor that surgeons spend little time considering if patients can endure the stress of surgery. Yet if frailty predicts adverse outcomes after such low-risk, ambulatory operations, it is important to identify and counsel frail patients before these relatively minor procedures. Therefore, this study examined the relationship among operative stress, frailty, and postoperative mortality among Veterans (n=432,828) who underwent a non-cardiac surgical procedure. Findings show:

  • Frailty was associated with increased 30-, 90- and 180-day mortality across all levels of operative stress. Frail patient mortality after low and moderate stress procedures was substantially higher than mortality rates usually associated with “high-risk” surgery.
  • Approximately 1 in 3 very frail Veterans died within 6 months of even minor surgery.

Daniel Hall, MD, MDiv, MHSc – principal investigator on this study – was awarded Gold Status for this project in the 2019 Diffusion of Excellence Shark Tank Competition. Dr. Hall’s Gold Status project features a highly effective clinical tool to screen frail elderly Veterans before they have surgery. A variety of research partners in this study have implemented frailty screening at VAMCs across the country: Omaha, Pittsburgh, Atlanta, Richmond, Phoenix, Palo Alto. At the Omaha VA Medical Center, the tool triggered administrative review of frail patients considering surgery and mortality rates among the frail dropped from 25% to 8%. Recently, the VHA Diffusion of Excellence initiative established a Memorandum of Understanding with the VA Pittsburgh Healthcare System to engage Daniel Hall, MD, MDiv, MHS in the national expansion of Preoperative Frailty Screening and Prehabilitation to other interested VA facilities seeking to broaden the care options available to patients who classify as "frail" prior to an elective surgery. In addition, Dr. Hall has developed a robust implementation guide to help other facilities navigate the implementation at their respective sites.

Shinall M, Arya S, Youk A, Varley P, Shah R, Massarweh N, Shireman P, Johanning J, and Hall D for the OSS (Operative Stress Score) Study Group. Association of Preoperative Patient Frailty and Operative Stress with Postoperative Mortality. JAMA Surgery. Nov 13, 2019; Epub ahead of print.

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