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Aging and disease    2020, Vol. 11 Issue (5) : 1276-1290     DOI: 10.14336/AD.2019.1024
Review Article |
Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis
Elke K.M Tjeertes1, Joris M.K van Fessem1, Francesco U.S Mattace-Raso2, Anton G.M Hoofwijk3, Robert Jan Stolker1, Sanne E Hoeks1,*
1Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
2Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
3Department of Surgery, Zuyderland Medical Center, Geleen, the Netherlands
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Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn’t.

Keywords frailty      surgery      outcome      older patients      non-cardiac surgery     
Corresponding Authors: Hoeks Sanne E   
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These authors contributed equally to this work.

Just Accepted Date: 26 November 2019   Issue Date: 21 September 2020
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Tjeertes Elke K.M
van Fessem Joris M.K
Mattace-Raso Francesco U.S
Hoofwijk Anton G.M
Stolker Robert Jan
Hoeks Sanne E
Cite this article:   
Tjeertes Elke K.M,van Fessem Joris M.K,Mattace-Raso Francesco U.S, et al. Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis[J]. Aging and disease, 2020, 11(5): 1276-1290.
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Figure 1.  PRISMA flowchart for study selection. This flowchart depicts the flow of information trough different phases of the systematic research.
Figure 2.  Forest plot 30-day mortality per frailty score. The number of events (deaths) and the total number of patients are shown for both frail and non-frail patients, stratified per frailty assessment tool.
Figure 3.  Forest plot postoperative complications per frailty score. The number of events (complications) and the total number of patients are shown for both frail and non-frail patients, stratified per frailty assessment tool.
AuthorNSettingPeriodDesignType of surgeryFrailty scoreDefinition of complicationQuality
Abt1193Multicenter cohort study (NSQIP)2006-2013ProspectiveHead and neck cancer surgeryModified frailty indexCD 4Good
Adams6727Multicenter cohort study (NSQIP)2005-2010ProspectiveHead and neck cancer surgeryModified frailty indexCD 4 or 5Good
Arya23027Multicenter cohort study (NSQIP)2005-2012ProspectiveVascular surgery (Open or EVAR)Modified frailty indexCD 4Good
Augustin13020Multicenter cohort study (NSQIP)2005-2010ProspectivePancreatic resectionsModified frailty indexCD 4Good
Brahmbhatt24645Multicenter cohort study (NSQIP)2005-2012ProspectiveInfrainguinal vascular surgeryModified frailty indexCD 4Good
Bras90Single-center cohort study2008-2013RetrospectiveSurgery for head and neck cancerGroningen frailty indicatorCD ≥ 2Fair
Chappidi2679Multicenter cohort study (NSQIP)2011-2013ProspectiveRadical cystectomyModified frailty indexCD 4 or 5Good
Chimukangara885Multicenter cohort study (NSQIP)2011-2013ProspectiveParaesofageal hernia repairModified frailty indexCD ≥ 3Fair
Cloney243Multicenter cohort study (NSQIP)2000-2012ProspectiveGlioblastoma surgeryModified frailty indexComplications (Glioma Outcomes Project System)Fair
Cooper415Multicenter cohort study2010-2013ProspectiveGeneral and orthopedic surgeryFrailty phenotype; frailty indexMajor complicationsFair
Courtney-Brooks37Single-center cohort study2011ProspectiveSurgery for gynecologic cancerFried frailty criteriaSurgical complications (NSQIP)Fair
Dale76Single-center cohort study2007-2011ProspectivePancreaticoduodenectomy4 (of 5) components of Fried frailty criteria; VES-13CD ≥ 3Fair
Dasgupta125Single-center cohort study2002-2003ProspectiveElective noncardiac surgery (82%) orthopedic)Edmonton frail scaleCardiac - / pulmonary comlications, PODFair
Farhat35334Multicenter cohort study (NSQIP)2005-2009ProspectiveEmergency general surgeryModified frailty indexAny complication (not mortality)Fair
Flexman52671Multicenter cohort study (NSQIP)2006-2012ProspectiveSpine surgeryModified frailty indexMajor complicationsGood
Hewitt102Multicenter cohort study2013ProspectiveEmergency general surgeryRockwood clinical frailty scaleNot reportedFair
Huisman328Multicenter cohort study2008-2012ProspectiveSurgery for solid tumorsGroningen frailty indicator; VES-13CD ≥ 3Good
Joseph220Single-center cohort study2012-2014ProspectiveEmergency general surgeryRockwood clinical frailty scaleSurgical complications (NSQIP)Fair
Kenig184Single-center cohort study2013-2014ProspectiveEmergency abdominal surgeryVES-13, GFI; Rockwood; Balducci; TRST; Geriatric-8Any complication (CD)Fair
Kim197Single-center cohort study2012-2014ProspectiveElective noncardiac surgeryFried frailty criteriaSurgical complications (NSQIP)Good
Kim275Single-center cohort study2011-2012ProspectiveElective intermediate-risk or high-risk surgeryMultidimensional frailty scoreSurgical complications (NSQIP)Good
Krishnan178Single-center cohort study2011ProspectiveLow trauma hip fracture surgeryFrailty indexNot reportedPoor
Kristjansson178Multicenter cohort study2008-2011ProspectiveElective surgery for colorectal cancerComprehensive geriatric assessmentCD ≥ 2Good
Kua82Single-center cohort study2013ProspectiveHip fracture surgeryEdmonton frail scale; (modified) Fried frailty criteriaAny complicationFair
Lascano41681Multicenter cohort study (NSQIP)2005-2013ProspectiveSurgery for urologic cancerModified frailty indexCD 4Good
Lasithiotakis57Single-center cohort study2008-2011ProspectiveElective laparoscopic cholecystectomyComprehensive geriatric assessmentAny complicationPoor
Leung63Single-center cohort study2007ProspectiveNoncardiac surgeryFried frailty criteriaNot reportedFair
Levy23104Multicenter cohort study (NSQIP)2008 to 2014ProspectiveRobot-assisted radical prostatectomyModified frailty indexCD 4Good
Li189Single-center cohort studyNot reportedProspectiveMajor intra-abdominal surgeryFried frailty criteriaCDFair
Louwers10300Multicenter cohort study (NSQIP)2005-2011ProspectiveHepatectomyModified frailty indexCD 4Good
Makary594Single-center cohort study2005-2006ProspectiveElective surgeryFried frailty criteriaSurgical complications (NSQIP)Good
McAdams-DeMarco537Single-center cohort study2008-2013ProspectiveKidney transplant surgeryFried frailty criteriaNot reportedFair
McIsaac202811Single-center cohort study2002-2012RetrospectiveMajor elective noncardiac surgeryACG frailty-defining diagnoses indicatorNot reportedGood
McIsaac125163Single-center cohort study2003-2012RetrospectiveTotal joint arthroplastyACG frailty-defining diagnoses indicatorICU-admissionGood
Melin44832Multicenter cohort study (NSQIP)2005-2011ProspectiveCarotid endarterectomyFrailty-based bedside Risk Analysis IndexNot reportedFair
Mogal9986Multicenter cohort study (NSQIP)2005-2012ProspectivePancreaticoduodenectomyModified frailty indexCD 3 or 4Good
Mosquera232352Multicenter cohort study (NSQIP)2005-2012Prospectiveelective high-risk surgeryModified frailty indexMajor and minor complicationsFair
Neuman12979Single-center cohort study1992-2005RetrospectiveElective colorectal cancer surgeryACG frailty-defining diagnoses indicatorReadmission within 30 daysFair
Obeid58448Multicenter cohort study (NSQIP)2005-2009ProspectiveLaparoscopic and open colectomyModified frailty indexCD 4 or 5Fair
Partridge125Single-center cohort study2011ProspectiveArterial vascular surgeryEdmonton frail scaleComposite postoperative complicationsFair
Pearl4330Multicenter cohort study (NSQIP)2011-2014ProspectiveRadical cystectomyModified frailty indexMajor in-hospital complicationsGood
Phan3920Multicenter cohort study (NSQIP)2010-2014ProspectiveElective anterior lumbar interbody fusion (ALIF) surgeryModified frailty indexAny complicationGood
Reisinger159Single-center cohort study2010-2012ProspectiveColorectal surgeryGroningen frailty indicatorSepsisGood
Revenig351Single-center cohort studyNot reportedProspectiveMajor intra-abdominal surgeryFried frailty criteriaCD 1-4Fair
Revenig80Single-center cohort studyNot reportedProspectiveIntra-abdominal minimally invasive surgeryFried frailty criteriaCD 1-4Fair
Revenig189Single-center cohort studyNot reportedProspectiveMajor intra-abdominal surgeryFried frailty criteriaAny complicationGood
Robinson72Single-center cohort study2007-2010ProspectiveColorectal surgeryRockwood clinical frailty scaleAny postoperative complication (VASQIP)Fair
Shin6148 ACDF; 817 PCFMulticenter cohort study (NSQIP)2005-2012ProspectiveCervical spine fusion; anterior cervical discectomy and fusion or posterior cervical fusionModified frailty indexCD 4Good
Shin14583 THA; 25223 TKAMulticenter cohort study (NSQIP)2005-2012ProspectiveTotal hip and knee arthroplastyModified frailty indexCD 4Good
Suskind95108Multicenter cohort study (NSQIP)2007-2013ProspectiveCommon urological surgeryModified frailty indexMajor and minor complicationsGood
Suskind20794Multicenter cohort study (NSQIP)2011-2013ProspectiveInpatient urological surgeryModified frailty indexNot reportedGood
Tan83Multicenter cohort study2008-2010ProspectiveColorectal surgeryFried frailty criteriaCD ≥ 2Fair
Tegels127Single-center cohort study2005-2012RetrospectiveSurgery for gastric cancerGroningen frailty indicatorCD ≥ 3Fair
Tsiouris1940Multicenter cohort study (NSQIP)2005-2010ProspectiveOpen lobectomyModified frailty indexCD 4Good
Ugolini46Single-center cohort study2009-2012ProspectiveElective colorectal cancer surgeryGroningen frailty indicator; VES-13Not reportedPoor
Uppal6551Multicenter cohort study (NSQIP)2008-2011ProspectiveSurgery for gynecologic cancerModified frailty indexCD 4 and 5Good
Table 1  Study demographics and method of determining frailty.
Figure 4.  Forest plot 1-year mortality. The number of events (one-year mortality) and the total number of patients are depicted for frail and non-frail patients.
Figure 5.  Forest plot postoperative delirium. The number of events (delirium) and the total number of patients are depicted for frail and non-frail patients.
Figure 6.  Forest plot discharge to specialized facility. The number of events (discharge to a specialized facility) and the total number of patients are depicted for frail and non-frail patients.
[1] Mangano DT (2004). Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth, 18:1-6.
[2] Partridge JS, Harari D, Dhesi JK (2012). Frailty in the older surgical patient: a review. Age Ageing, 41:142-147.
[3] Kristensen SD, Knuuti J, Saraste A, Anker S, Botker HE, De Hert S, et al. (2014). 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol, 31:517-573.
[4] Lee DH, Buth KJ, Martin BJ, Yip AM, Hirsch GM (2010). Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation, 121:973-978.
[5] Polanczyk CA, Marcantonio E, Goldman L, Rohde LE, Orav J, Mangione CM, et al. (2001). Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med, 134:637-643.
[6] Browner WS, Li J, Mangano DT (1992). In-hospital and long-term mortality in male veterans following noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA, 268:228-232.
[7] Arozullah AM, Khuri SF, Henderson WG, Daley J, Participants in the National Veterans Affairs Surgical Quality Improvement P (2001). Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med, 135:847-857.
[8] Huber CH, Goeber V, Berdat P, Carrel T, Eckstein F (2007). Benefits of cardiac surgery in octogenarians--a postoperative quality of life assessment. Eur J Cardiothorac Surg, 31:1099-1105.
[9] Fruitman DS, MacDougall CE, Ross DB (1999). Cardiac surgery in octogenarians: can elderly patients benefit? Quality of life after cardiac surgery. Ann Thorac Surg, 68:2129-2135.
[10] Filsoufi F, Rahmanian PB, Castillo JG, Chikwe J, Silvay G, Adams DH (2007). Results and predictors of early and late outcomes of coronary artery bypass graft surgery in octogenarians. J Cardiothorac Vasc Anesth, 21:784-792.
[11] Baskett R, Buth K, Ghali W, Norris C, Maas T, Maitland A, et al. (2005). Outcomes in octogenarians undergoing coronary artery bypass grafting. CMAJ, 172:1183-1186.
[12] Sundermann S, Dademasch A, Rastan A, Praetorius J, Rodriguez H, Walther T, et al. (2011). One-year follow-up of patients undergoing elective cardiac surgery assessed with the Comprehensive Assessment of Frailty test and its simplified form. Interact Cardiovasc Thorac Surg, 13:119-123; discussion 123.
[13] Xue QL (2011). The frailty syndrome: definition and natural history. Clin Geriatr Med, 27:1-15.
[14] 2017. In Integrated Care for Older People: Guidelines on Community-Level Interventions to Manage Declines in Intrinsic Capacity. Geneva.
[15] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ, 339:b2700.
[16] Dindo D, Demartines N, Clavien PA (2004). Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 240:205-213.
[17] De J, Wand AP (2015). Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients. Gerontologist, 55:1079-1099.
[18] Kristensen SD, Knuuti J (2014). New ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J, 35:2344-2345.
[19] Hayden JA, Cote P, Bombardier C (2006). Evaluation of the quality of prognosis studies in systematic reviews. Ann Intern Med, 144:427-437.
[20] Graham PL, Moran JL (2012). Robust meta-analytic conclusions mandate the provision of prediction intervals in meta-analysis summaries. J Clin Epidemiol, 65:503-510.
[21] IntHout J, Ioannidis JP, Rovers MM, Goeman JJ (2016). Plea for routinely presenting prediction intervals in meta-analysis. BMJ Open, 6:e010247.
[22] Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I (2013). Accumulating deficits model of frailty and postoperative mortality and morbidity: Its application to a national database. J Surg Res, 183:104-110.
[23] Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K (2008). A standard procedure for creating a frailty index. BMC Geriatr, 8:24.
[24] Fuchshuber PR, Greif W, Tidwell CR, Klemm MS, Frydel C, Wali A, et al. (2012). The power of the National Surgical Quality Improvement Program--achieving a zero pneumonia rate in general surgery patients. Perm J, 16:39-45.
[25] Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. (2001). Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 56:M146-156.
[26] Hewitt J, Long S, Carter B, Bach S, McCarthy K, Clegg A (2018). The prevalence of frailty and its association with clinical outcomes in general surgery: a systematic review and meta-analysis. Age Ageing, 47:793-800.
[27] Oakland K, Nadler R, Cresswell L, Jackson D, Coughlin PA (2016). Systematic review and meta-analysis of the association between frailty and outcome in surgical patients. Ann R Coll Surg Engl, 98:80-85.
[28] Lin HS, Watts JN, Peel NM, Hubbard RE (2016). Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr, 16:157.
[29] Panayi AC, Orkaby AR, Sakthivel D, Endo Y, Varon D, Roh D, et al. (2018). Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg.
[30] Wang J, Zou Y, Zhao J, Schneider DB, Yang Y, Ma Y, et al. (2018). The Impact of Frailty on Outcomes of Elderly Patients After Major Vascular Surgery: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg, 56:591-602.
[31] Bouwmeester W, Zuithoff NP, Mallett S, Geerlings MI, Vergouwe Y, Steyerberg EW, et al. (2012). Reporting and methods in clinical prediction research: a systematic review. PLoS Med, 9:1-12.
[32] Ehlert BA, Najafian A, Orion KC, Malas MB, Black JH, Abularrage CJ (2016). Validation of a modified Frailty Index to predict mortality in vascular surgery patients. J Vasc Surg, 63:1595e1592-1601e1592.
[33] Abt NB, Richmon JD, Koch WM, Eisele DW, Agrawal N (2016). Assessment of the predictive value of the modified frailty index for Clavien-Dindo grade IV critical care complications in major head and neck cancer operations. JAMA Otolaryngol Head Neck Surg, 142:658-664.
[34] Ali R, Schwalb JM, Nerenz DR, Antoine HJ, Rubinfeld I (2016). Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg Spine, 25:537-541.
[35] Tsiouris A, Hammoud ZT, Velanovich V, Hodari A, Borgi J, Rubinfeld I (2013). A modified frailty index to assess morbidity and mortality after lobectomy. J Surg Res, 183:40-46.
[36] Uppal S, Igwe E, Rice LW, Spencer RJ, Rose SL (2015). Frailty index predicts severe complications in gynecologic oncology patients. Gynecol Oncol, 137:98-101.
[37] Akpan A, Roberts C, Bandeen-Roche K, Batty B, Bausewein C, Bell D, et al. (2018). Standard set of health outcome measures for older persons. BMC Geriatr, 18:36.
[38] Tjeertes EK, Ultee KH, Stolker RJ, Verhagen HJ, Bastos Goncalves FM, Hoofwijk AG, et al. (2016). Perioperative Complications are Associated With Adverse Long-Term Prognosis and Affect the Cause of Death After General Surgery. World J Surg, 40:2581-2590.
[39] Wynter-Blyth V, Moorthy K (2017). Prehabilitation: preparing patients for surgery. BMJ, 358:j3702.
[40] Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP (2011). Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery, 149:830-840.
[41] Moorthy K, Wynter-Blyth V (2017). Prehabilitation in perioperative care. Br J Surg, 104:802-803.
[42] Carli F, Scheede-Bergdahl C (2015). Prehabilitation to enhance perioperative care. Anesthesiol Clin, 33:17-33.
[43] Lumpkin S, Stitzenberg K (2018). Regionalization and Its Alternatives. Surg Oncol Clin N Am, 27:685-704.
[44] Krishnan M, Beck S, Havelock W, Eeles E, Hubbard RE, Johansen A (2014). Predicting outcome after hip fracture: Using a frailty index to integrate comprehensive geriatric assessment results. Age Ageing, 43:122-126.
[45] Cooper Z, Rogers SO, Ngo L, Guess J, Schmitt E, Jones RN, et al. (2016). Comparison of Frailty Measures as Predictors of Outcomes After Orthopedic Surgery. J Am Geriatr Soc, 64:2464-2471.
[46] Slaets JP (2006). Vulnerability in the elderly: frailty. Med Clin North Am, 90:593-601.
[47] Bras L, Peters TTA, Wedman J, Plaat BEC, Witjes MJH, van Leeuwen BL, et al. (2015). Predictive value of the Groningen Frailty Indicator for treatment outcomes in elderly patients after head and neck, or skin cancer surgery in a retrospective cohort. Clin Otolaryngol, 40:474-482.
[48] Huisman MG, Audisio RA, Ugolini G, Montroni I, Vigano A, Spiliotis J, et al. (2015). Screening for predictors of adverse outcome in onco-geriatric surgical patients: A multicenter prospective cohort study. Eur J Surg Oncol, 41:844-851.
[49] Reisinger KW, Van Vugt JLA, Tegels JJW, Snijders C, Hulsewé KWE, Hoofwijk AGM, et al. (2015). Functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery. Ann Surg, 261:345-352.
[50] Tegels JJW, de Maat MFG, Hulsewé KWE, Hoofwijk AGM, Stoot JHMB (2014). Value of Geriatric Frailty and Nutritional Status Assessment in Predicting Postoperative Mortality in Gastric Cancer Surgery. J Gastrointest Surg, 18:439-446.
[51] Ugolini G, Pasini F, Ghignone F, Zattoni D, Reggiani MLB, Parlanti D, et al. (2015). How to select elderly colorectal cancer patients for surgery: a pilot study in an Italian academic medical center. Cancer Biol Med, 12:302-307.
[52] Kenig J, Zychiewicz B, Olszewska U, Barczynski M, Nowak W (2015). Six screening instruments for frailty in older patients qualified for emergency abdominal surgery. Arch Gerontol Geriatr, 61:437-442.
[53] Kua J, Ramason R, Rajamoney G, Chong MS (2016). Which frailty measure is a good predictor of early post-operative complications in elderly hip fracture patients? Arch Orthop Trauma Surg, 136:639-647.
[54] Li JL, Henderson MA, Revenig LM, Sweeney JF, Kooby DA, Maithel SK, et al. (2016). Frailty and one-year mortality in major intra-abdominal operations This study was presented at the World Congress of Endourology in London in October 2015. J Surg Res, 203:507.e501-512.e501.
[55] Revenig LM, Canter DJ, Kim S, Liu Y, Sweeney JF, Sarmiento JM, et al. (2015). Report of a simplified frailty score predictive of short-term postoperative morbidity and mortality. J Am Coll Surg, 220:904-911.e901.
[56] Revenig LM, Canter DJ, Master VA, Maithel SK, Kooby DA, Pattaras JG, et al. (2014). A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery. J Endourol, 28:476-480.
[57] Tan KY, Kawamura YJ, Tokomitsu A, Tang T (2012). Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized. Am J Surg, 204:139-143.
[58] Kim S, Marsh AP, Rustowicz L, Roach C, Leng XI, Kritchevsky SB, et al. (2016). Self-reported mobility in older patients predicts early postoperative outcomes after elective noncardiac surgery. Anesthesiology, 124:815-825.
[59] Leung JM, Tsai TL, Sands LP (2011). Preoperative frailty in older surgical patients is associated with early postoperative delirium. Anesth Analg, 112:1199-1201.
[60] Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. (2010). Frailty as a Predictor of Surgical Outcomes in Older Patients. J. Am. Coll. Surg., 210:901-908.
[61] McAdams-Demarco MA, Law A, King E, Orandi B, Salter M, Gupta N, et al. (2015). Frailty and mortality in kidney transplant recipients. Am J Transplant, 15:149-154.
[62] Revenig LM, Canter DJ, Taylor MD, Tai C, Sweeney JF, Sarmiento JM, et al. (2013). Too frail for surgery? Initial results of a large multidisciplinary prospective study examining preoperative variables predictive of poor surgical outcomes. J Am Coll Surg, 217:665-670.e661.
[63] Courtney-Brooks M, Tellawi AR, Scalici J, Duska LR, Jazaeri AA, Modesitt SC, et al. (2012). Frailty: An outcome predictor for elderly gynecologic oncology patients. Gynecol Oncol, 126:20-24.
[64] Adams P, Ghanem T, Stachler R, Hall F, Velanovich V, Rubinfeld I (2013). Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg, 139:783-789.
[65] Arya S, Kim SI, Duwayri Y, Brewster LP, Veeraswamy R, Salam A, et al. (2015). Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities. J Vasc Surg, 61:324-331.
[66] Augustin T, Burstein MD, Schneider EB, Morris-Stiff G, Wey J, Chalikonda S, et al. (2016). Frailty predicts risk of life-threatening complications and mortality after pancreatic resections. Surgery, 160:987-996.
[67] Brahmbhatt R, Brewster LP, Shafii S, Rajani RR, Veeraswamy R, Salam A, et al. (2016). Gender and frailty predict poor outcomes in infrainguinal vascular surgery. J Surg Res, 201:156-165.
[68] Chappidi MR, Kates M, Patel HD, Tosoian JJ, Kaye DR, Sopko NA, et al. (2016). Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy. Urol Oncol Semin Orig Invest.
[69] Chimukangara M, Frelich MJ, Bosler ME, Rein LE, Szabo A, Gould JC (2016). The impact of frailty on outcomes of paraesophageal hernia repair. J Surg Res, 202:259-266.
[70] Cloney M, D'Amico R, Lebovic J, Nazarian M, Zacharia BE, Sisti MB, et al. (2016). Frailty in Geriatric Glioblastoma Patients: A Predictor of Operative Morbidity and Outcome. World Neurosurg, 89:362-367.
[71] Farhat JS, Velanovich V, Falvo AJ, Horst HM, Swartz A, Patton JHJr, et al. (2012). Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg, 72:1526-1531.
[72] Flexman AM, Charest-Morin R, Stobart L, Street J, Ryerson CJ (2016). Frailty and postoperative outcomes in patients undergoing surgery for degenerative spine disease. Spine J, 16:1315-1323.
[73] Lascano D, Pak JS, Kates M, Finkelstein JB, Silva M, Hagen E, et al. (2015). Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools. Urol Oncol Semin Orig Invest, 33:426.e421-426.e412.
[74] Levy I, Finkelstein M, Bilal KH, Palese M (2017). Modified frailty index associated with Clavien-Dindo IV complications in robot-assisted radical prostatectomies: A retrospective study. Urol Oncol Semin Orig Invest.
[75] Louwers L, Schnickel G, Rubinfeld I (2016). Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: Analysis of the National Surgical Quality Improvement Project database. Am J Surg, 211:1071-1076.
[76] Mogal H, Vermilion SA, Dodson R, Hsu FC, Howerton R, Shen P, et al. (2017). Modified Frailty Index Predicts Morbidity and Mortality After Pancreaticoduodenectomy. Ann Surg Oncol:1-8.
[77] Mosquera C, Spaniolas K, Fitzgerald TL (2016). Impact of frailty on surgical outcomes: The right patient for the right procedure. Surgery, 160:272-280.
[78] Obeid NM, Azuh O, Reddy S, Webb S, Reickert C, Velanovich V, et al. (2012). Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: Exploring frailty and aggressive laparoscopic approaches. J Trauma Acute Care Surg, 72:878-883.
[79] Pearl JA, Patil D, Filson CP, Arya S, Alemozaffar M, Master VA, et al. (2017). Patient Frailty and Discharge Disposition Following Radical Cystectomy. Clin Genitourin Cancer.
[80] Phan K, Kim JS, Lee NJ, Somani S, Di Capua J, Kothari P, et al. (2017). Frailty is associated with morbidity in adults undergoing elective anterior lumbar interbody fusion (ALIF) surgery. Spine J, 17:538-544.
[81] Suskind AM, Jin C, Cooperberg MR, Finlayson E, Boscardin WJ, Sen S, et al. (2016). Preoperative Frailty Is Associated With Discharge to Skilled or Assisted Living Facilities After Urologic Procedures of Varying Complexity. Urology, 97:25-32.
[82] Suskind AM, Walter LC, Jin C, Boscardin J, Sen S, Cooperberg MR, et al. (2016). Impact of frailty on complications in patients undergoing common urological procedures: A study from the American College of Surgeons National Surgical Quality Improvement database. BJU Int.
[83] Shin JI, Keswani A, Lovy AJ, Moucha CS (2016). Simplified Frailty Index as a Predictor of Adverse Outcomes in Total Hip and Knee Arthroplasty. J Arthroplasty, 31:2389-2394.
[84] Shin JI, Kothari P, Phan K, Kim JS, Leven D, Lee NJ, et al. (2017). Frailty Index as a Predictor of Adverse Postoperative Outcomes in Patients Undergoing Cervical Spinal Fusion. Spine, 42:304-310.
[85] Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K (2006). Validity and reliability of the Edmonton Frail Scale. Age Ageing, 35:526-529.
[86] Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M (2009). Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr, 48:78-83.
[87] Partridge JSL, Fuller M, Harari D, Taylor PR, Martin FC, Dhesi JK (2015). Frailty and poor functional status are common in arterial vascular surgical patients and affect postoperative outcomes. Int J Surg, 18:57-63.
[88] Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. (2005). A global clinical measure of fitness and frailty in elderly people. CMAJ, 173:489-495.
[89] Hewitt J, Moug SJ, Middleton M, Chakrabarti M, Stechman MJ, McCarthy K (2015). Prevalence of frailty and its association with mortality in general surgery. Am J Surg, 209:254-259.
[90] Joseph B, Zangbar B, Pandit V, Fain M, Mohler MJ, Kulvatunyou N, et al. (2016). Emergency General Surgery in the Elderly: Too Old or Too Frail? Presented orally at the Surgical Forum of the American College of Surgeons 100th Annual Clinical Congress, San Francisco, CA, October 2014. J Am Coll Surg, 222:805-813.
[91] Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland JCJr, Moss M (2013). Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg, 206:544-550.
[92] Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ, et al. (2001). The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc, 49:1691-1699.
[93] Dale W, Hemmerich J, Kamm A, Posner MC, Matthews JB, Rothman R, et al. (2014). Geriatric assessment improves prediction of surgical outcomes in older adults undergoing pancreaticoduodenectomy: A prospective cohort study. Ann Surg, 259:960-965.
[94] Lieberman R AC, Weiner JP2003. Development and Evaluation of the Johns Hopkins University Risk Adjustment Models for Medicare ? Choice Plan Payment.: Baltimore, MD; Johns Hopkins University.
[95] Neuman HB, Weiss JM, Leverson G, O’Connor ES, Greenblatt DY, Loconte NK, et al. (2013). Predictors of Short-Term Postoperative Survival after Elective Colectomy in Colon Cancer Patients ≥80 Years of Age. Ann Surg Oncol, 20:1427-1435.
[96] McIsaac DI, Bryson GL, van Walraven C (2016). Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac Surgery: A Population-Based Cohort Study. JAMA Surg.
[97] McIsaac DI, Beaule PE, Bryson GL, Van Walraven C (2016). The impact of frailty on outcomes and healthcare resource usage after total joint arthroplasty: a population-based cohort study. Bone Joint J, 98-B:799-805.
[98] Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. (2010). Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg, 210:901-908.
[99] Melin AA, Schmid KK, Lynch TG, Pipinos II, Kappes S, Longo GM, et al. (2015). Preoperative frailty risk analysis index to stratify patients undergoing carotid endarterectomy. J Vasc Surg, 61:683-689.
[100] Balducci L, Beghe C (2000). The application of the principles of geriatrics to the management of the older person with cancer. Crit Rev Oncol Hematol, 35:147-154.
[101] Kristjansson SR, Nesbakken A, Jordhøy MS, Skovlund E, Audisio RA, Johannessen HO, et al. (2010). Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: A prospective observational cohort study. Crit Rev Oncol Hematol, 76:208-217.
[102] Lasithiotakis K, Petrakis J, Venianaki M, Georgiades G, Koutsomanolis D, Andreou A, et al. (2013). Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients. Surg Endosc Interv Tech, 27:1144-1150.
[103] Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, et al. (2014). Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg., 149:633-640.
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