title: Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools.
abstract: OBJECTIVE
  To retrospectively validate and compare a modified frailty index predicting adverse outcomes and other risk stratification tools among patients undergoing urologic oncological surgeries.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program was queried from 2005 to 2013 to identify patients undergoing cystectomy, prostatectomy, nephrectomy, and nephroureterectomy. Using the Canadian Study of Health and Aging Frailty Index, 11 variables were matched to the database; 4 were also added because of their relevance in oncology patients. The incidence of mortality, Clavien-Dindo IV complications, and adverse events were assessed with patients grouped according to their modified frailty index score.
  
  
  RESULTS
  We identified 41,681 patients who were undergoing surgery for presumed urologic malignancy. Patients with a high frailty index score of >0.20 had a 3.70 odds of a Clavien-Dindo IV event (CI: 2.865-4.788, P<0.0005) and a 5.95 odds of 30-day mortality (CI: 3.72-9.51, P<0.0005) in comparison with nonfrail patients after adjusting for race, sex, age, smoking history, and procedure. Using C-statistics to compare the sensitivity and specificity of the predictive ability of different models per risk stratification tool and the Akaike information criteria to assess for the fit of the models with the data, the modified frailty index was comparable or superior to the Charlson comorbidity index but inferior to the American Society of Anesthesiologists Risk Class in predicting 30-day mortality or Clavien-Dindo IV events. When the modified frailty index was augmented with the American Society of Anesthesiologists Risk Class, the new index was superior in all aspects in comparison to other risk stratification tools.
  
  
  CONCLUSIONS
  Existing risk stratification tools may be improved by incorporating variables in our 15-point modified frailty index as well as other factors such as walking speed, exhaustion, and sarcopenia to fully assess frailty. This is relevant in diseases such as kidney and prostate cancer, where surveillance and other nonsurgical interventions exist as alternatives to a potentially complicated surgery. In these scenarios, our modified frailty index augmented by the American Society of Anesthesiologists Risk Class may help inform which patients have increased surgical complications that may outweigh the benefit of surgery although this index needs prospective validation.
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York. Electronic address: dl2178@columbia.edu.
authors.forename: Danny
authors.initials: D
authors.lastname: Lascano
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: Jamie S
authors.initials: JS
authors.lastname: Pak
authors.affiliation: The James Buchanan Brady Urological Institute, Johns Hopkins Medicine/Johns Hopkins University. Baltimore, MD.
authors.forename: Max
authors.initials: M
authors.lastname: Kates
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: Julia B
authors.initials: JB
authors.lastname: Finkelstein
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: Mark
authors.initials: M
authors.lastname: Silva
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Hagen
authors.affiliation: Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY.
authors.forename: Arindam
authors.initials: A
authors.lastname: RoyChoudhury
authors.affiliation: The James Buchanan Brady Urological Institute, Johns Hopkins Medicine/Johns Hopkins University. Baltimore, MD.
authors.forename: Trinity J
authors.initials: TJ
authors.lastname: Bivalacqua
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: G Joel
authors.initials: GJ
authors.lastname: DeCastro
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: Mitchell C
authors.initials: MC
authors.lastname: Benson
authors.affiliation: The J. Bentley Squier Urologic Clinic, Department of Urology at New York-Presbyterian/Columbia University College of Physicians and Surgeons and the Herbert Irvine Comprehensive Cancer Center, New York, New York.
authors.forename: James M
authors.initials: JM
authors.lastname: McKiernan
mesh_terms: D000368:Aged; D015897:Comorbidity; D005260:Female; D016330:Frail Elderly; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D014571:Urologic Neoplasms / Q000150:complications / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000009:adverse effects*
keywords: Frail elderly; Patient survival; Preoperative evaluation; Surgical outcomes; Urologic oncology