Study Shows Frailty’s Effect On Mortality in Emergency General Surgery

WESTLAKE VILLAGE, Calif.—Healthcare professionals may want to consider frailty as a crucial factor when making treatment decisions for patients with emergency general surgery conditions, according to research presented at the 2023 annual meeting of the Surgical Infection Society.

The retrospective analysis of more than 300,000 patients highlighted the significance of frailty in determining mortality risk in various emergency general surgery (EGS) conditions, with the risk differing significantly depending on the disease. Based on these findings, the study authors noted that a more comprehensive and personalized approach to treating frail patients could enable better informed decisions and ultimately improve outcomes.

“This study sheds light on the significant impact of frailty on mortality in various EGS conditions and the potential benefits of operative or nonoperative management depending on the specific condition and patient frailty level,” said Vanessa Ho, MD, an associate professor of surgery at Case Western Reserve University School of Medicine, in Ohio.

As Dr. Ho reported, frailty—an age-related loss of physiologic reserve or impaired ability to respond to stress—has been shown to have a direct stepwise association with mortality across surgical specialties and operation types. The study conducted by Dr. Ho and her colleagues examined how frailty affects 90-day outcomes with mortality after operative and nonoperative management in common EGS conditions causing abdominal sepsis.

The researchers used the National Readmissions Database to identify patients 65 years and older with diagnoses of appendicitis, diverticulitis, cholecystitis, peptic ulcer and ischemic bowel. Frailty was assessed using the deficit accumulation method, with patients grouped into quintiles based on their frailty scores.

The primary outcome was time to death, truncated at 90 days, and Cox proportional hazard modeling was used to analyze the data, adjusting for age, sex and the presence of shock. A total of 304,573 patients were included in the study, with a mean age of 77 years.

The results showed that the effect of frailty on mortality was greatest in lower-risk operations. According to Dr. Ho, operative management favored survival across all frailty quintiles in appendicitis and cholecystitis, indicating that frailty alone may not be a strong enough indicator to reject a surgical intervention in these diseases. In contrast, nonoperative management had a survival advantage in diverticulitis and peptic ulcer disease across all frailty levels.

The study also revealed that the degree of frailty’s impact on survival differed among the EGS conditions. For example, appendicitis had a 1.2% mortality rate, while ischemic bowel had a considerably higher rate at 24.4%.

“For ischemic bowel conditions, the mortality rate was high regardless of frailty level, and there was no significant difference between operative and nonoperative management,” Dr. Ho said. “These findings illustrate the importance of considering the specific EGS condition when assessing the role of frailty in treatment decisions.

“The presence of shock and age were also important factors in determining mortality risk, while male patients had worse outcomes,” Dr. Ho added.

According to Dr. Ho, future research could explore the relationship between frailty and outcomes in operative and nonoperative management, as well as investigate other factors that may influence the decision-making process for frail patients with EGS conditions.

The abstract discussant, Amani D. Politano, MD, a vascular surgeon and an assistant professor of surgery at Oregon Health & Science University School of Medicine, in Portland, highlighted the concept of “chronologic and physiologic age mismatch.”

“There are patients in our service who are old, but not nearly as old as their numeric age would indicate, and there are patients who seem much older,” Dr. Politano explained. “This is what frailty scores aim to capture.”

Dr. Politano also raised questions regarding frailty assessment in EGS patients. According to her, using 38 ICD-10 codes for determining frailty in a preoperative setting may not be as replicable as alternative frailty indices that could be implemented more easily in clinical practice.

Regarding the study results, Dr. Politano found the hazard ratios in low-risk surgical conditions intriguing and sought further clarification of their implications. She also noted that patients in the nonoperative group might have higher mortality rates due to delayed surgical intervention. Finally, Dr. Politano questioned whether these findings support deferring to nonoperative management for certain patient populations.

“Has this study influenced or changed your approach to treating elderly patients with EGS conditions?” she asked.

“Since starting this research, I’ve become more aggressive about operative management for lower-risk diseases, like appendicitis and cholecystitis,” Dr. Ho replied. “If you delay surgery for these patients, you can end up with recurrent diseases and infections, and then they are no longer operative candidates.”