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Original Investigation | SURGICAL CARE OF THE AGING POPULATION

Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk

Sun-wook Kim, MD1; Ho-Seong Han, MD, PhD2,4; Hee-won Jung, MD1; Kwang-il Kim, MD, PhD1,3; Dae Wook Hwang, MD, PhD2,4; Sung-Bum Kang, MD, PhD2,4; Cheol-Ho Kim, MD, PhD1,3
[+] Author Affiliations
1Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
2Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
3Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
4Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
JAMA Surg. 2014;149(7):633-640. doi:10.1001/jamasurg.2014.241.
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Published online

Importance  The number of geriatric patients who undergo surgery has been increasing, but there are insufficient tools to predict postoperative outcomes in the elderly.

Objective  To design a predictive model for adverse outcomes in older surgical patients.

Design, Setting, and Participants  From October 19, 2011, to July 31, 2012, a single tertiary care center enrolled 275 consecutive elderly patients (aged ≥65 years) undergoing intermediate-risk or high-risk elective operations in the Department of Surgery.

Main Outcomes and Measures  The primary outcome was the 1-year all-cause mortality rate. The secondary outcomes were postoperative complications (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission), length of hospital stay, and discharge to nursing facility.

Results  Twenty-five patients (9.1%) died during the follow-up period (median [interquartile range], 13.3 [11.5-16.1] months), including 4 in-hospital deaths after surgery. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Malignant disease and low serum albumin levels were more common in the patients who died. Among the geriatric assessment domains, Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition were associated with increased mortality rates. A multidimensional frailty score model composed of the above items predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification (area under the receiver operating characteristic curve, 0.821 vs 0.647; P = .01). The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model’s cutoff point (>5 vs ≤5). High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = .003) and longer hospital stays after surgery (median [interquartile range], 9 [5-15] vs 6 [3-9] days; P < .001).

Conclusions and Relevance  The multidimensional frailty score based on comprehensive geriatric assessment is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery.

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Figures

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Figure 1.
Flow of Patients Through Study

The final study population included 275 elderly patients undergoing intermediate-risk to high-risk operations after comprehensive geriatric assessment (CGA).

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Figure 2.
Area Under Receiver Operating Characteristic Curve (AUC) for All-Cause Mortality Rate (A), Discharge to Nursing Facility (B), and Postoperative Complications (C)

ASA indicates American Society of Anesthesiologists; MFS, multidimensional frailty score.

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Figure 3.
Number of Patients and 1-Year All-Cause Mortality Rate by Multidimensional Frailty Score

Bars represent numbers of patients (and deaths); black line, mortality rate. As scores increase, the occurrence of the primary outcome (death) increased, and the slope for mortality rates suddenly became steep for patients with scores of 5 or above.

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Figure 4.
Cumulative All-Cause Mortality Rate According to Risk Stratification Based on Multidimensional Frailty Score (MFS)

Kaplan-Meier plots are shown for all-cause mortality rates in low-risk vs high-risk patient groups; results are not adjusted. Numbers at the bottom represent patients who were followed up alive.

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