Preoperative vulnerability assessment leads to improved 1-year survival

A quality improvement study showed that implementing a frailty screening initiative before elective surgery was associated with more referrals of frailty patients for additional evaluation and improved survival at 1 year. rice field.

After adjusting for confounders, there was a 22% reduction in mortality at 180 days post-surgery (OR 0.78, 95% CI 0.67-0.91) and an 18% reduction after implementation of the Epic Best Practice Alert (BPA) . After 1 year (OR 0.82, 95% CI 0.72-0.92, P.both <0.001), reported Daniel E. Hall, MD, MDiv, MHSc, University of Pittsburgh Medical Center (UPMC) Presbyterian Church and co-authors.

An interrupted time series analysis showed that 1-year mortality was increasing at a rate of 0.12% per month before BPA implementation, but began to decrease by 0.04% per month after implementation. The estimated 1-year mortality in BPA-triggered patients changed by -4.2% (95% CI -6.0% to -2.4%), the authors said. JAMA surgery.

“These observations demonstrate that the intervention is effective and sustainable, two key characteristics in determining the usefulness of quality improvement efforts within the hospital system,” said Hall and team. I am writing.

He and his colleagues also found a significant increase in the proportion of frail patients referred to primary care physicians (9.8% vs. 24.6%) or preoperative care clinics (1.3% vs. 11.4%) after the introduction of BPA. did (both P.<0.001).

previous research by the same researcher showed that implementing a broad screening tool for frailty, known as the Risk Analysis Index (RAI), is feasible in large hospital systems and can reliably estimate postoperative outcome.

“Despite the documented success of routine frailty screening, whether efforts to screen for and mitigate frailty-related risks lead to improved outcomes at the level of the screened population? Significant knowledge gaps remain regarding the

and Accompanying commentaryDeborah M. Stein, MD, MPH, of the University of Maryland School of Medicine, Baltimore, and colleagues noted that while frailty assessment is an important tool to help manage the care of older patients, “this system-level intervention is not sustainable.” The infrastructure required to achieve successful outcomes includes system-wide buy-in of multiple stakeholders, staff education, adaptation of screening tools to workflows, and surgeon compliance, but this is universal. It may not be realistic, but it is feasible.”

They also questioned whether frail patients were less likely to undergo elective surgery and the long-term outcomes of patients who did not undergo surgery. Despite the uncontrolled trial design and interrupted time-series analyzes aimed at controlling for long-term trends in postoperative mortality, selection bias remains a concern,” they noted.

In this study, surgeons at all UPMC clinics in nine specialties were encouraged to complete the RAI assessment beginning in July 2016 for all patients considering elective surgery. Since July 2017, additional her BPA alerted clinicians to her 42 or more patients with RAI.

A total of 50,463 patients with 1-year follow-up after surgery were included, 22,722 pre-implementation and 27,741 post-implementation. The average age he was 56.7 years old was 57.6% female and 87.8% Caucasian. Patient characteristics were similar between periods.

Of the patients, 1,367 had an RAI of 42 or greater, triggering frail BPA, and surgeons acknowledged the warning in all cases.

Because the study was not randomized, Hall and team noted that causal conclusions could not be drawn and that there may be unobserved confounding factors. It also does not describe specific elements of services offered by physicians or preoperative care clinics.

Also of note, we were unable to quantify whether their intervention influenced decisions to choose non-surgical care for frail patients.