Study Suggests Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans

BACKGROUND:
Half of Veterans older than 65 years seeking colorectal or cardiac surgery are frail or pre-frail, doubling the costs of care, as well as the risks for post-operative mortality and complications. Based on similar findings in other populations, there is consensus that this increased risk should inform shared decision-making – and that it may be useful to identify patients for palliative care consultation. Investigators in this study implemented a quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. A brief screening tool called the "risk analysis index" (RAI) was developed for use in this study, and approximately 10% of all patients scheduled for elective surgery were identified as frail (RAI score of >21). Frail patients were then strongly encouraged by surgical services to undergo pre-operative palliative care consultation. For this analysis, investigators obtained all palliative care consultations ordered at the Nebraska Western Iowa VAMC. From 2006 to 2013, a total of 310 palliative care consultations were ordered for surgical patients: 160 before initiation of frailty screening (1/1/11) and 150 after initiation of the program. From the date of the index operation and death, investigators calculated overall survival as well as 30-, 180-, and 360-day mortality. Mortality data were confirmed on 3/31/14, and the overall length of survival was calculated up to this date.

FINDINGS:

• A systematic fraility-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort (71% at 180 days), study models suggest that for every four patients screened, one death was prevented or delayed at 180 days.
• After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons (57% vs. 24%), and they were more likely to take place before the index operation (52% vs. 26%). Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality.

LIMITATIONS:

• This study sample included only Veterans with formally ordered palliative care consultations, which probably reflects a bias toward the sickest and most frail of all patients undergoing elective surgery.
• Only formal palliative care consultations ordered in the medical record were analyzed; thus, investigators cannot account for any increase in the informal palliative care offered by phyiscians.
• This was a small, single institution study; a larger study would be needed to confirm findings.

IMPLICATIONS:

• Findings suggest that systematic frailty screening provides an objective basis for appropriate surgical palliative care consultation that leads to reduced post-operative mortality in frail Veterans.

AUTHOR/FUNDING INFORMATION:
Dr. Hall is part of HSR&D's Center for Health Equity Research & Promotion, Pittsburgh, PA.

Ernst K, Hall D, Schmid K, et al. Surgical Palliative Care Consultations Over Time in Relationship to Systemwide Frailty Screening. JAMA Surgery. September 10, 2014;e-pub ahead of print.