Commentary: Presurgical frailty assessment can predict adverse outcomes in patients undergoing cardiac surgery… but where do we go from here?

Central MessagePresurgical frailty assessments identify those at risk of adverse outcomes independent of age. Patient-centered perioperative interventions are needed to reduce adverse outcomes and health care costs.See Article page 491 in the December 2021 issue.Past research has highlighted frailty assessment as a means of identifying who may be at an increased risk of poor outcomes associated with the stress of cardiac surgery.1Lee J.A. Yanagawa B. An K.R. Arora R.C. Verma S. Friedrich J.O. Canadian Cardiovascular Surgery Meta-Analysis Working GroupFrailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients.J Cardiothorac Surg. 2021; 16: 184https://doi.org/10.1186/s13019-021-01541-8Crossref PubMed Scopus (10) Google Scholar In the December 2021 issue of JTCVS Open, Sarkar and colleagues2Sarkar S. MacLeod J.B. Hassan A. Dutton D.J. Brunt K.R. Légaré J.F. An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costs.J Thorac Cardiovasc Surg Open. 2021; 8: 491-502https://doi.org/10.1016/j.xjon.2021.10.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar build on this knowledge using a retrospective hospital record-based frailty assessment of 3463 cardiac surgery patients. Independent of the traditional metric of age, the generated tool predicted prolonged hospitalization, nonhome discharge, 30-day readmission, 30-day mortality, and increased hospital cost. While this study provides an excellent example of knowledge mobilization by using a registry-based frailty risk stratification in a specific clinical setting, recommending potential changes to clinical practice should be approached with caution when commonly used clinical tools for risk stratification are not provided as comparison or for assessing additive value.Another critical element of this analysis is the reliance on administrative data for the generated 20-point frailty score that fails to identify the intervenable aspects of frailty. The approach of Sarkar and colleagues is also retrospective, identifying frailty largely through the presence of cardiac-focused comorbidities (frailty index), which may identify different individuals compared with functional assessments.3Angioni D. Macaron T. Takeda C. Sourdet S. Cesari M. Virecoulon Giudici K. et al.Can we distinguish age-related frailty from frailty related to diseases? Data from the MAPT Study.J Nutr Health Aging. 2020; 24: 1144-1151https://doi.org/10.1007/s12603-020-1518-xCrossref PubMed Scopus (7) Google Scholar However, the frailty stratification identifies those most at risk who may benefit from subsequent intensive assessment, such as the Comprehensive Geriatric Assessment, an approach recommended by the International Conference on Frailty and Sarcopenia Research group.4Ruiz J.G. Dent E. Morley J.E. Merchant R.A. Beilby J. Beard J. et al.Screening for and managing the person with frailty in primary care: ICFSR consensus guidelines.J Nutr Health Aging. 2020; 24: 920-927https://doi.org/10.1007/s12603-020-1492-3Crossref PubMed Scopus (33) Google Scholar Beyond that, the approach of Sarkar and colleagues provides an opportunity for clinicians to use that risk stratification to refer at-risk individuals to targeted interventions before their surgery. Such an intervention has recently been described by the bundle of protocols advocated by the Enhanced Recovery After Surgery (ERAS)–Cardiac Society. The proposed bundle of enhancing recovery protocols includes recommendations5Engelman D.T. Ben Ali W. Williams J.B. Perrault L.P. Reddy V.S. Arora R.C. et al.Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations.JAMA Surg. 2019; 154: 755-766https://doi.org/10.1001/jamasurg.2019.1153Crossref PubMed Scopus (322) Google Scholar such as implementing prehabilitation to improve an individual's readiness for surgery.6Boreskie K.F. Hay J.L. Kehler D.S. Johnston N.M. Rose A.V. Oldfield C.J. et al.Prehabilitation: the right medicine for older frail adults anticipating transcatheter aortic valve replacement, coronary artery bypass graft, and other cardiovascular care.Clin Geriatr Med. 2019; 35: 571-585https://doi.org/10.1016/j.cger.2019.07.006Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Prehabilitation programs have been recommended to include nutrition optimization, exercise training, and worry reduction in the NEW approach.7Arora R.C. Brown C.H. Sanjanwala R.M. McKelvie R. “NEW” prehabilitation: a 3-way approach to improve postoperative survival and health-related quality of life in cardiac surgery patients.Can J Cardiol. 2018; 34: 839-849https://doi.org/10.1016/j.cjca.2018.03.020Abstract Full Text Full Text PDF PubMed Scopus (41) Google ScholarSex-based differences require a much more in-depth exploration, as called for by the Sex and Gender Equity in Research (SAGER) reporting guidelines and the Lancet Women and Cardiovascular Disease Commission.8Vogel B. Acevedo M. Appelman Y. Bairey Merz C.N. Chieffo A. Figtree G.A. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438https://doi.org/10.1016/S0140-6736(21)00684-XAbstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar,9Heidari S. Babor T.F. De Castro P. Tort S. Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use.Res Integr Peer Rev. 2016; 1: 2https://doi.org/10.1186/s41073-016-0007-6Crossref PubMed Google Scholar Notably, Sarkar and colleagues report the sex distribution of their sample in addition to reporting the results of their sex-based analyses. Female sex was found to be an independent predictor of the composite outcome (nonhome discharge and increased length of stay) and associated with an approximately $2105 greater average hospital cost. However, the data were not provided disaggregated by sex. Data disaggregation, even if presented in the Supplemental material, is essential to promote a greater understanding of sex and gender-based differences in cardiovascular health by facilitating the generation of future hypotheses and future meta-analyses.8Vogel B. Acevedo M. Appelman Y. Bairey Merz C.N. Chieffo A. Figtree G.A. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438https://doi.org/10.1016/S0140-6736(21)00684-XAbstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar,9Heidari S. Babor T.F. De Castro P. Tort S. Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use.Res Integr Peer Rev. 2016; 1: 2https://doi.org/10.1186/s41073-016-0007-6Crossref PubMed Google ScholarWhere do we go from here? Sarkar and colleagues2Sarkar S. MacLeod J.B. Hassan A. Dutton D.J. Brunt K.R. Légaré J.F. An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costs.J Thorac Cardiovasc Surg Open. 2021; 8: 491-502https://doi.org/10.1016/j.xjon.2021.10.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar demonstrate administrative data-derived frailty assessment identifies risk in an increasingly vulnerable population referred for cardiac surgery; this necessitates action to improve outcomes. The development and evaluation of multimodal enhanced recovery programs are needed. Moreover, care pathways must focus on outcomes that matter to patients with frailty. Researchers must consider sex and gender-based differences and include patient-centered outcomes such as quality of life in addition to traditional measures of mortality, hospitalization, and cerebrovascular complications to further improvements in care.10Benstoem C. Moza A. Meybohm P. Stoppe C. Autschbach R. Devane D. et al.A core outcome set for adult cardiac surgery trials: a consensus study.PLoS One. 2017; 12: e0186772https://doi.org/10.1371/journal.pone.0186772Crossref PubMed Scopus (14) Google Scholar Presurgical frailty assessments identify those at risk of adverse outcomes independent of age. Patient-centered perioperative interventions are needed to reduce adverse outcomes and health care costs. Presurgical frailty assessments identify those at risk of adverse outcomes independent of age. Patient-centered perioperative interventions are needed to reduce adverse outcomes and health care costs. See Article page 491 in the December 2021 issue. See Article page 491 in the December 2021 issue. Past research has highlighted frailty assessment as a means of identifying who may be at an increased risk of poor outcomes associated with the stress of cardiac surgery.1Lee J.A. Yanagawa B. An K.R. Arora R.C. Verma S. Friedrich J.O. Canadian Cardiovascular Surgery Meta-Analysis Working GroupFrailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients.J Cardiothorac Surg. 2021; 16: 184https://doi.org/10.1186/s13019-021-01541-8Crossref PubMed Scopus (10) Google Scholar In the December 2021 issue of JTCVS Open, Sarkar and colleagues2Sarkar S. MacLeod J.B. Hassan A. Dutton D.J. Brunt K.R. Légaré J.F. An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costs.J Thorac Cardiovasc Surg Open. 2021; 8: 491-502https://doi.org/10.1016/j.xjon.2021.10.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar build on this knowledge using a retrospective hospital record-based frailty assessment of 3463 cardiac surgery patients. Independent of the traditional metric of age, the generated tool predicted prolonged hospitalization, nonhome discharge, 30-day readmission, 30-day mortality, and increased hospital cost. While this study provides an excellent example of knowledge mobilization by using a registry-based frailty risk stratification in a specific clinical setting, recommending potential changes to clinical practice should be approached with caution when commonly used clinical tools for risk stratification are not provided as comparison or for assessing additive value. Another critical element of this analysis is the reliance on administrative data for the generated 20-point frailty score that fails to identify the intervenable aspects of frailty. The approach of Sarkar and colleagues is also retrospective, identifying frailty largely through the presence of cardiac-focused comorbidities (frailty index), which may identify different individuals compared with functional assessments.3Angioni D. Macaron T. Takeda C. Sourdet S. Cesari M. Virecoulon Giudici K. et al.Can we distinguish age-related frailty from frailty related to diseases? Data from the MAPT Study.J Nutr Health Aging. 2020; 24: 1144-1151https://doi.org/10.1007/s12603-020-1518-xCrossref PubMed Scopus (7) Google Scholar However, the frailty stratification identifies those most at risk who may benefit from subsequent intensive assessment, such as the Comprehensive Geriatric Assessment, an approach recommended by the International Conference on Frailty and Sarcopenia Research group.4Ruiz J.G. Dent E. Morley J.E. Merchant R.A. Beilby J. Beard J. et al.Screening for and managing the person with frailty in primary care: ICFSR consensus guidelines.J Nutr Health Aging. 2020; 24: 920-927https://doi.org/10.1007/s12603-020-1492-3Crossref PubMed Scopus (33) Google Scholar Beyond that, the approach of Sarkar and colleagues provides an opportunity for clinicians to use that risk stratification to refer at-risk individuals to targeted interventions before their surgery. Such an intervention has recently been described by the bundle of protocols advocated by the Enhanced Recovery After Surgery (ERAS)–Cardiac Society. The proposed bundle of enhancing recovery protocols includes recommendations5Engelman D.T. Ben Ali W. Williams J.B. Perrault L.P. Reddy V.S. Arora R.C. et al.Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations.JAMA Surg. 2019; 154: 755-766https://doi.org/10.1001/jamasurg.2019.1153Crossref PubMed Scopus (322) Google Scholar such as implementing prehabilitation to improve an individual's readiness for surgery.6Boreskie K.F. Hay J.L. Kehler D.S. Johnston N.M. Rose A.V. Oldfield C.J. et al.Prehabilitation: the right medicine for older frail adults anticipating transcatheter aortic valve replacement, coronary artery bypass graft, and other cardiovascular care.Clin Geriatr Med. 2019; 35: 571-585https://doi.org/10.1016/j.cger.2019.07.006Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Prehabilitation programs have been recommended to include nutrition optimization, exercise training, and worry reduction in the NEW approach.7Arora R.C. Brown C.H. Sanjanwala R.M. McKelvie R. “NEW” prehabilitation: a 3-way approach to improve postoperative survival and health-related quality of life in cardiac surgery patients.Can J Cardiol. 2018; 34: 839-849https://doi.org/10.1016/j.cjca.2018.03.020Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Sex-based differences require a much more in-depth exploration, as called for by the Sex and Gender Equity in Research (SAGER) reporting guidelines and the Lancet Women and Cardiovascular Disease Commission.8Vogel B. Acevedo M. Appelman Y. Bairey Merz C.N. Chieffo A. Figtree G.A. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438https://doi.org/10.1016/S0140-6736(21)00684-XAbstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar,9Heidari S. Babor T.F. De Castro P. Tort S. Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use.Res Integr Peer Rev. 2016; 1: 2https://doi.org/10.1186/s41073-016-0007-6Crossref PubMed Google Scholar Notably, Sarkar and colleagues report the sex distribution of their sample in addition to reporting the results of their sex-based analyses. Female sex was found to be an independent predictor of the composite outcome (nonhome discharge and increased length of stay) and associated with an approximately $2105 greater average hospital cost. However, the data were not provided disaggregated by sex. Data disaggregation, even if presented in the Supplemental material, is essential to promote a greater understanding of sex and gender-based differences in cardiovascular health by facilitating the generation of future hypotheses and future meta-analyses.8Vogel B. Acevedo M. Appelman Y. Bairey Merz C.N. Chieffo A. Figtree G.A. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438https://doi.org/10.1016/S0140-6736(21)00684-XAbstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar,9Heidari S. Babor T.F. De Castro P. Tort S. Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use.Res Integr Peer Rev. 2016; 1: 2https://doi.org/10.1186/s41073-016-0007-6Crossref PubMed Google Scholar Where do we go from here? Sarkar and colleagues2Sarkar S. MacLeod J.B. Hassan A. Dutton D.J. Brunt K.R. Légaré J.F. An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costs.J Thorac Cardiovasc Surg Open. 2021; 8: 491-502https://doi.org/10.1016/j.xjon.2021.10.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar demonstrate administrative data-derived frailty assessment identifies risk in an increasingly vulnerable population referred for cardiac surgery; this necessitates action to improve outcomes. The development and evaluation of multimodal enhanced recovery programs are needed. Moreover, care pathways must focus on outcomes that matter to patients with frailty. Researchers must consider sex and gender-based differences and include patient-centered outcomes such as quality of life in addition to traditional measures of mortality, hospitalization, and cerebrovascular complications to further improvements in care.10Benstoem C. Moza A. Meybohm P. Stoppe C. Autschbach R. Devane D. et al.A core outcome set for adult cardiac surgery trials: a consensus study.PLoS One. 2017; 12: e0186772https://doi.org/10.1371/journal.pone.0186772Crossref PubMed Scopus (14) Google Scholar An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costsJTCVS OpenVol. 8PreviewGlobally, an increasing number of vulnerable or frail patients are undergoing cardiac surgery. However, large-scale frailty data are often limited by the need for time-consuming frailty assessments. This study aimed to (1) create a retrospective registry-based frailty score (FS), (2) determine its effect on outcomes and age, and (3) health care costs. Full-Text PDF Open Access

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