0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac Surgery A Population-Based Cohort Study

Daniel I. McIsaac, MD, MPH, FRCPC1,2,3,4; Gregory L. Bryson, MD, FRCPC, MSc1,3,4; Carl van Walraven, MD, FRCPC, MSc1,3,4
[+] Author Affiliations
1University of Ottawa, Ottawa, Ontario, Canada
2Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
3Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
4Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
JAMA Surg. 2016;151(6):538-545. doi:10.1001/jamasurg.2015.5085.
Text Size: A A A
Published online

Importance  Single-center studies identify frailty as a risk factor for 30-day postoperative mortality. The long-term and population-level effect of frailty on postoperative mortality is, to our knowledge, poorly described, as are the interactions of frailty with important predictors of mortality.

Objective  To measure the population-level effect of patient frailty on, and its association with, 1-year postoperative mortality.

Design, Setting, and Participants  Population-based retrospective cohort study in Ontario, Canada, with data collected between April 1, 2002 and March 31, 2012. Analysis was performed from December 2014 to March 2015. All patients were community-dwelling individuals aged 65 years or older on the day of elective, major noncardiac surgery.

Exposure  Frailty, as defined by the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. The ACG frailty-defining diagnoses indicator is a binary variable that uses 12 clusters of frailty-defining diagnoses

Main Outcomes and Measures  One-year all-cause postoperative mortality.

Results  Of 202 811 patients, 6289 (3.1%) were frail (mean [SD] age, 77 [7] years). Within 1 year, 13.6% (n = 855) of frail and 4.8% (n = 9433) of nonfrail patients died. Adjustment for sociodemographic and surgical confounders resulted in a hazard ratio of 2.23 (95% CI, 2.08-2.40). The interaction between frailty and postoperative time demonstrated an increased relative hazard for death in frail patients (hazard ratio, 35.58; 95% CI, 29.78-40.19) on postoperative day 3. The association between frailty and increased risk of death decreased with patient age (HR, 2.66; 95% CI, 2.28-3.10 at age 65; HR, 1.63; 95% CI, 1.36-1.95 at age 90). Significant variations in the increased risk for death in frail patients existed between different surgery types and was strongest after total joint arthroplasty (HR, 3.79; 95% CI, 3.21-4.47 for hip replacement; HR, 2.68; 95% CI, 2.10-3.42 for knee replacement).

Conclusions and Relevance  At a population level, preoperative frailty-defining diagnoses were associated with a significantly increased risk of 1-year mortality that was particularly notable in the early postoperative period, in younger patients, and after joint arthroplasty.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Figures

Place holder to copy figure label and caption
Figure 1.
Time-Dependent Adjusted Relative Hazard of Mortality in Frail vs Nonfrail Patients

A, This plot shows the hazard ratio (adjusted for patient age, sex, neighborhood income, and surgical type) and 95% CIs for the association between frailty and 1-year mortality following surgery. The hazard ratio was determined for each postoperative day. Hazard ratios above 1 indicate an increased risk of death in frail compared with nonfrail patients. Hazard ratios beyond 90 days did not change significantly and are not displayed. The x-axis is also truncated for display purposes. The horizontal dotted line indicates the null value of the hazard ratio (1.0). B, This plot shows the hazard function for frail and nonfrail patients over the first postoperative year. The hazard function represents the instantaneous risk of death at any time. The line for frail patients is expected to be less smooth owing to the smaller sample size.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Impact of Frailty on Postoperative Mortality by Patient Age

This plot presents the hazard ratio (adjusted for patient sex, neighborhood income, and surgical type) and 95% CIs for the association between frailty and 1-year mortality following surgery. The hazard ratio was determined for all patient ages. Hazard ratios above 1 indicate an increased risk of death in frail patients. The horizontal dotted line indicates the null value of the hazard ratio (1.0).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Hazard Ratio for Effect of Interaction Between Frailty and Surgery Type on 1-Year Mortality Risk

The hazard ratio (adjusted for patient age, sex, and neighborhood income) measuring the association between frailty and 1-year mortality is presented for each surgical type. Hazard ratios whose lower 95% CI excludes 1 indicate a significantly increased risk of 1-year death in frail patients.

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

3,173 Views
0 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
brightcove.createExperiences();