Impact of frailty on all-cause mortality in older neurosurgical patients with prolonged hospitalization: a retrospective observational study

Uzoukwu, Cynthia1; Owodunni, Oluwafemi P.2,3,*; Peter-Okaka, Uchenna4; Courville, Evan N.3,5; Conti, Joseph T.6; Gagliardi, Thomas A.6; Schmidt, Meic H.3,5; Bowers, Christian A.3

1Northeast Ohio Medical University, Rootstown, OH, USA

2Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA

3Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA

4West Virginia University School of Medicine, Morgantown, WV, USA

5Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA

6New York Medical College School of Medicine, Valhalla, New York, NY, USA

*Correspondence to: Oluwafemi P. Owodunni, MD, MPH, oowodunni@salud.unm.edu.

Abstract

Hospital performance is increasingly measured by length of stay, which accounts for 90% of inter-patient cost variations. We examined the impact of frailty on all-cause mortality in neurosurgical patients with length of stay > 30 days and analyzed the discrimination and independent association of the risk analysis index, 5-factor modified frailty index, and advanced patient age for predicting all-cause mortality. The older patients who underwent neurosurgical procedures between 2012 and 2020 in the American College of Surgeons National Surgical Quality Improvement Program, with length of stay > 30 days were included in this retrospective observational study. Receiver operating characteristic curves were employed to compare the discrimination and multivariable analyses for associations of the risk analysis index, 5-factor modified frailty index advanced patient age and all-cause mortality. Secondary analyses were performed for spine and cranial procedures. Overall, 3474 patients were included, patients had a median age of 60 years (IQR: 49–70), were male (58.6%), white (47.9%), and underwent spine (46.4%) and cranial (51.9%) procedures. Major complications (33.9%), and median length of stay 38 days (IQR: 33–48) were observed. Risk analysis index demonstrated superior discrimination (C-statistic 0.72, 95% confidence interval 0.69–0.74) than 5-factor modified frailty index (C-statistic 0.57, 95% confidence interval 0.54–0.60) and advanced patient age (C-statistic 0.59, 95% confidence interval 0.55–0.62). Risk analysis index also demonstrated a dose-dependent relationship and larger effects in multivariable analysis (P < 0.001). Similar trends were observed for spine and cranial procedures in both Receiver operating characteristic and multivariable analysis. Taken together, frailty increased all-cause mortality dose-dependently, and risk analysis index exhibited a higher discrimination threshold and larger effect estimates than the 5-factor modified frailty index and advanced patient age. This study reflects the importance of preoperative assessment of frailty in the management of older neurosurgical patients and supports the use of risk analysis index in preoperative assessment to improve clinical outcomes of older patients. By identifying and assessing frailty, healthcare professionals can better personalize treatment plans for older patients to address age-related changes and challenges.

老年神经外科长期住院患者衰弱状态对全因死亡率的影响：回顾性观察研究

摘要

医院绩效越来越多地通过住院时间（LOS）来衡量，而住院时间占患者间费用差异的90%。本研究旨在探讨衰弱对神经外科患者住院时间超过30天的全因死亡率的影响，并评估风险分析指数（RAI）、5因素改良衰弱指数（mFI-5）和患者年龄在预测全因死亡率中的独立关联性。通过回顾性研究2012-2020年间美国外科医师学会国家外科质量改进计划（ACS-NSQIP）数据库中接受神经外科手术且住院时间超过30天的患者，使用接收者操作特征（ROC）曲线比较了RAI、mFI-5和患者年龄对全因死亡率的预测能力。研究共纳入3474名患者，患者的中位年龄为 60 岁（IQR：49-70），男性（58.6%），白人（47.9%）。结果显示RAI在预测全因死亡率方面具有更高的判别能力（C统计量0.72，95%CI 0.69-0.74），优于mFI-5（C统计量0.57 C 统计量 0.57，95%CI 0.54-0.60）和患者年龄（C统计量0.59，95%CI 0.55-0.62）。此外，RAI还表现出与全因死亡率的剂量依赖性关系，在多变量分析中效果更大（P<0.001）。这一发现在脊柱和颅脑手术亚组分析中也得到了一致的验证。这些结果表明，衰弱会增加老年神经外科长期住院患者全因死亡率，并且RAI在预测这一结果方面比mFI-5和患者年龄具有更大的价值。该研究反映了术前评估衰弱状态在老年神经外科患者管理中的重要性，支持在术前评估中使用RAI，以改善患者临床结局。通过识别和评估衰弱，医疗专业人员可以更好地为老年患者制定个性化的治疗计划，以应对与年龄相关的变化和挑战。