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
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.
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.
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.
Author
N
Setting
Period
Design
Type of surgery
Frailty score
Definition of complication
Quality
Abt
1193
Multicenter cohort study (NSQIP)
2006-2013
Prospective
Head and neck cancer surgery
Modified frailty index
CD 4
Good
Adams
6727
Multicenter cohort study (NSQIP)
2005-2010
Prospective
Head and neck cancer surgery
Modified frailty index
CD 4 or 5
Good
Arya
23027
Multicenter cohort study (NSQIP)
2005-2012
Prospective
Vascular surgery (Open or EVAR)
Modified frailty index
CD 4
Good
Augustin
13020
Multicenter cohort study (NSQIP)
2005-2010
Prospective
Pancreatic resections
Modified frailty index
CD 4
Good
Brahmbhatt
24645
Multicenter cohort study (NSQIP)
2005-2012
Prospective
Infrainguinal vascular surgery
Modified frailty index
CD 4
Good
Bras
90
Single-center cohort study
2008-2013
Retrospective
Surgery for head and neck cancer
Groningen frailty indicator
CD ≥ 2
Fair
Chappidi
2679
Multicenter cohort study (NSQIP)
2011-2013
Prospective
Radical cystectomy
Modified frailty index
CD 4 or 5
Good
Chimukangara
885
Multicenter cohort study (NSQIP)
2011-2013
Prospective
Paraesofageal hernia repair
Modified frailty index
CD ≥ 3
Fair
Cloney
243
Multicenter cohort study (NSQIP)
2000-2012
Prospective
Glioblastoma surgery
Modified frailty index
Complications (Glioma Outcomes Project System)
Fair
Cooper
415
Multicenter cohort study
2010-2013
Prospective
General and orthopedic surgery
Frailty phenotype; frailty index
Major complications
Fair
Courtney-Brooks
37
Single-center cohort study
2011
Prospective
Surgery for gynecologic cancer
Fried frailty criteria
Surgical complications (NSQIP)
Fair
Dale
76
Single-center cohort study
2007-2011
Prospective
Pancreaticoduodenectomy
4 (of 5) components of Fried frailty criteria; VES-13
Elective anterior lumbar interbody fusion (ALIF) surgery
Modified frailty index
Any complication
Good
Reisinger
159
Single-center cohort study
2010-2012
Prospective
Colorectal surgery
Groningen frailty indicator
Sepsis
Good
Revenig
351
Single-center cohort study
Not reported
Prospective
Major intra-abdominal surgery
Fried frailty criteria
CD 1-4
Fair
Revenig
80
Single-center cohort study
Not reported
Prospective
Intra-abdominal minimally invasive surgery
Fried frailty criteria
CD 1-4
Fair
Revenig
189
Single-center cohort study
Not reported
Prospective
Major intra-abdominal surgery
Fried frailty criteria
Any complication
Good
Robinson
72
Single-center cohort study
2007-2010
Prospective
Colorectal surgery
Rockwood clinical frailty scale
Any postoperative complication (VASQIP)
Fair
Shin
6148 ACDF; 817 PCF
Multicenter cohort study (NSQIP)
2005-2012
Prospective
Cervical spine fusion; anterior cervical discectomy and fusion or posterior cervical fusion
Modified frailty index
CD 4
Good
Shin
14583 THA; 25223 TKA
Multicenter cohort study (NSQIP)
2005-2012
Prospective
Total hip and knee arthroplasty
Modified frailty index
CD 4
Good
Suskind
95108
Multicenter cohort study (NSQIP)
2007-2013
Prospective
Common urological surgery
Modified frailty index
Major and minor complications
Good
Suskind
20794
Multicenter cohort study (NSQIP)
2011-2013
Prospective
Inpatient urological surgery
Modified frailty index
Not reported
Good
Tan
83
Multicenter cohort study
2008-2010
Prospective
Colorectal surgery
Fried frailty criteria
CD ≥ 2
Fair
Tegels
127
Single-center cohort study
2005-2012
Retrospective
Surgery for gastric cancer
Groningen frailty indicator
CD ≥ 3
Fair
Tsiouris
1940
Multicenter cohort study (NSQIP)
2005-2010
Prospective
Open lobectomy
Modified frailty index
CD 4
Good
Ugolini
46
Single-center cohort study
2009-2012
Prospective
Elective colorectal cancer surgery
Groningen frailty indicator; VES-13
Not reported
Poor
Uppal
6551
Multicenter cohort study (NSQIP)
2008-2011
Prospective
Surgery for gynecologic cancer
Modified frailty index
CD 4 and 5
Good
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.
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2020,
Vol. 11
