title: Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days.
abstract: As the US population ages, the number of operations performed on elderly patients will likely increase. Frailty predicts postoperative mortality and morbidity more than age alone, thus presenting opportunities to identify the highest-risk surgical patients and improve their outcomes.
  
  
  
  To examine the effect of the Frailty Screening Initiative (FSI) on mortality and complications by comparing the surgical outcomes of a cohort of surgical patients treated before and after implementation of the FSI.
  
  
  
  This single-site, facility-wide, prospective cohort quality improvement project studied all 9153 patients from a level 1b Veterans Affairs medical center who presented for major, elective, noncardiac surgery from October 1, 2007, to July 1, 2014.
  
  
  
  Assessment of preoperative frailty in all patients scheduled for elective surgery began in July 2011. Frailty was assessed with the Risk Analysis Index (RAI), and the records of all frail patients (RAI score, ≥21) were flagged for administrative review by the chief of surgery (or designee) before the scheduled operation. On the basis of this review, clinicians from surgery, anesthesia, critical care, and palliative care were notified of the patient's frailty and associated surgical risks; if indicated, perioperative plans were modified based on team input.
  
  
  
  Postoperative mortality at 30, 180, and 365 days.
  
  
  
  From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16).
  
  
  
  Implementation of the FSI was associated with reduced mortality, suggesting the feasibility of widespread screening of patients preoperatively to identify frailty and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Additional investigation is required to establish a causal connection.
authors.affiliation: Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania2Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Hall
authors.affiliation: Surgical Service Line, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia4Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia.
authors.forename: Shipra
authors.initials: S
authors.lastname: Arya
authors.affiliation: Department of Biostatistics, University of Nebraska Medical Center, Omaha.
authors.forename: Kendra K
authors.initials: KK
authors.lastname: Schmid
authors.affiliation: Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha7Department of Surgery, University of Nebraska Medical Center, Omaha8Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Carlson
authors.affiliation: Department of Extended Care and Rehabilitation, VA Nebraska-Western Iowa Health Care System, Omaha.
authors.forename: Pierre
authors.initials: P
authors.lastname: Lavedan
authors.affiliation: Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha10Department of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City.
authors.forename: Travis L
authors.initials: TL
authors.lastname: Bailey
authors.affiliation: Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha.
authors.forename: Georgia
authors.initials: G
authors.lastname: Purviance
authors.affiliation: Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha.
authors.forename: Tammy
authors.initials: T
authors.lastname: Bockman
authors.affiliation: Office of Health Operations and Management, Department of Veterans Affairs, Veterans Health Administration, Washington, DC12Department of Surgery, George Washington University School of Medicine, Washington, DC.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Lynch
authors.affiliation: Department of Surgery, University of Nebraska Medical Center, Omaha8Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha.
authors.forename: Jason M
authors.initials: JM
authors.lastname: Johanning
mesh_terms: D000368:Aged; D017558:Elective Surgical Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data*; D006304:Health Status; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality*; D057234:Preoperative Period; D011446:Prospective Studies; D058996:Quality Improvement; D018570:Risk Assessment / Q000379:methods; D015996:Survival Rate; D013997:Time Factors; D014481:United States; D014493:United States Department of Veterans Affairs