Original Investigation |

Frailty as a Predictor of Morbidity and Mortality in Inpatient Head and Neck Surgery

Peter Adams, MD1; Tamer Ghanem, MD, PhD2; Robert Stachler, MD2; Francis Hall, MBChB2; Vic Velanovich, MD3; Ilan Rubinfeld, MD, MBA1
[+] Author Affiliations
1Department of Surgery, Henry Ford Hospital, Detroit, Michigan
2Department of Otolaryngology–Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan
3Division of General Surgery, University of South Florida, Tampa
JAMA Otolaryngol Head Neck Surg. 2013;139(8):783-789. doi:10.1001/jamaoto.2013.3969.
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Published online

Importance  The increasing number of elderly and comorbid patients undergoing surgical procedures raises interest in better identifying patients at increased risk of morbidity and mortality, independent of age. Frailty has been identified as a predictor of surgical complications.

Objective  To establish the implications of frailty as a predictor of morbidity and mortality in inpatient otolaryngologic operations.

Design  Retrospective review of medical records.

Setting  National Surgical Quality Improvement Program (NSQIP) participating hospitals.

Patients  NSQIP participant use files were used to identify 6727 inpatients who underwent operations performed by surgeons specializing in otolaryngology between 2005 and 2010. The study sample was 50.3% male and 10.2% African American, with a mean (range) age of 54.7 (16-90) years.

Main Outcomes and Measures  A previously described modified frailty index (mFI) was calculated on the basis of NSQIP variables. The effect of increasing frailty on morbidity and mortality was evaluated using univariate analysis. Multivariate logistic regression was used to compare mFI with age, ASA, and wound classification.

Results  The mean (range) mFI was 0.07 (0-0.73). As the mFI increased from 0 (no frailty-associated variables) to 0.45 (5 of 11) or higher, mortality risk increased from 0.2% to 11.9%. The risk of Clavien-Dindo grade IV complications increased from 1.2% to 26.2%. The risk of all complications increased from 9.5% to 40.5%. All results were significant at P < .001. In a multivariate logistic regression model to predict mortality or serious complication, mFI became the dominant significant predictor.

Conclusions and Relevance  The mFI is significantly associated with morbidity and mortality in this retrospective survey. Additional study with prospective analysis and external validation is needed. The mFI may provide an improved understanding of preoperative risk, which would facilitate perioperative optimization, risk stratification, and counseling related to outcomes.

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Figure 1.
The 70 Items of the Canadian Study on Health and Aging Frailty Index
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Figure 2.
The 11 Items of the Modified Frailty Index
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Figure 3.
Frailty Distribution: Inpatient vs Outpatient

Mean (SD) modified frailty index (mFI), inpatients, 0.07 (0.09); outpatients, 0.04 (0.07).

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Figure 4.
Complications With Increasing Modified Frailty Index

CL4 indicates Clavien-Dindo grade IV; mFI, modified frailty index.

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