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Frailty is associated with an increased risk of undesirable postoperative outcomes across surgical subspecialties, including complications, length of stay, discharge to a skilled or assisted-living facility,1–3 and morbidity.4 With the rapidly increasing older population, frailty assessment in the preoperative setting is becoming an increasingly important, yet rarely performed, screening tool that is recommended by both the American College of Surgeons and the American Geriatric Society.5
In this issue of JAMA Surgery, Hall et al6 share their experience with the implementation of the Frailty Screening Initiative at a Veterans Affairs medical center. They used the Risk Analysis Index, which is a deficit accumulation model of frailty, to identify frail individuals to undergo further review before their anticipated operation. Compared with a historical control of patients in the same medical center before implementation of the Frailty Screening Initiative, patients who underwent frailty screening had a decrease in overall mortality from 1.6% to 0.7%. However, this decrease was most pronounced among frail individuals, who had decreases from 12.2% to 3.8% for 30-day mortality, 23.9% to 7.7% for 180-day mortality, and 34.5% to 11.7% for 365-day mortality.
As noted by the authors, this study likely benefitted from the Hawthorne effect, whereby patients received more scrutinized preoperative care, potentially leading to a positive selection bias by excluding poor operative candidates from undergoing surgery. Although this finding may suggest more appropriate use of surgery, there are certainly situations (ie, palliative surgery) when alleviation of symptoms and pain, not improved 1-year mortality, is the most important outcome. Excluding patients with limited life expectancy from surgical interventions that may improve symptom management out of fear of poor mortality statistics is a real concern. The authors also note that their use of preoperative palliative care consultation resulted in postoperative care that was more in line with patient preferences and provide an example of when physicians pressed aggressive care that was in line with the patient’s stated preoperative wishes when the patient’s family requested consideration of care de-escalation. Although preoperative goal setting and documentation are indeed important, it is essential that physicians not cling too rigidly to aggressive therapy that has clearly become futile and harmful in the name of adhering to preoperative treatment preferences that may longer be realistic.7
Despite these limitations and cautions, this study serves as a timely example of how frailty assessment was successfully implemented in one medical center. Although these authors used the Risk Analysis Index, there are numerous other ways to effectively measure frailty, and the selection of the measurement tool should take into account the feasibility of implementation in each unique clinical setting. The time is now for surgeons to incorporate frailty into their preoperative assessment of older patients and to focus more on the patient’s individual goals of care, which may not always include surgery. At the very least, preoperative frailty assessment serves as a portal into the overall surgical fitness of an individual and leads the surgeon to consider the whole person in addition to the surgical problem at hand.
Conflict of Interest Disclosures: Dr Suskind reported receiving support from the National Institute of Diabetes and Digestive and Kidney Diseases (K12 Urologic Research Career Development Program) and the National Institutes of Health National Institute on Aging Grants for Early Medical/Surgical Specialists’ Transition to Aging Research. Dr Finlayson reported receiving support from the National Institute on Aging.