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Publication Briefs

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

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.


  • 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.


  • 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.


  • 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.

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

PubMed Logo 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.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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