Updated NSQIP Frailty Index

Transcription

1 Updated NSQIP Frailty Index Adam P. Johnson, MD, MPH; 1 Sarah E. Koller, MD; 2 Emily A. Busch, MD; 2 Matt M. Philp, MD; 2 Howard Ross, MD; 2 Paul J DiMuzio, MD; 1 Scott W. Cowan, MD; 1 Henry A. Pitt, MD 2 1 Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 2 Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA American College of Surgeons Quality and Safety Conference July 23, 2017

2 Disclosure Speaker: Adam P. Johnson, MD/MPH I do not have any relevant financial relationships with any commercial interest that pertains to the content of my presentation.

3 Age distribution in recent times and the future

4 But OLD does not equal FRAIL

5 Frailty Models and Assessments Can frailty assessment be simplified? Previous NSQIP scores are unweighted and use voluntary/retired variables

6 Project Aims Develop and validate a simplified, updated frailty index in colorectal patients Validate in an independent group of vascular patients and compare frailty effects between these patient populations

7 Methods Patient selection: ACS NSQIP PUF File Colectomy patients. 60% Random sample Development sample (68,877 patients) 40% Random sample Validation sample (45,312 patients) ACS NSQIP PUF File Vascular Procedure Targeted Carotid endarterectomy, carotid stenting, endovascular and open abdominal aorta aneurysm repair, endovascular and open aortoiliac, endovascular and open lower extremity (41,839 patients) Variables: Aligned ACS NSQIP items with items on the Canada Study of Health and Aging (CSHA) Frailty Index (FI) (Rockwood 2005)

8 Methods Score Development: Univariable chi-squared analysis to confirm association with Death and Serious Morbidity (DSM) Multivariable, backwards step-wise logistic regression to identify variables most strongly associated with DSM and assign weights based on derived odds ratios. Score Validation: ROC analysis to determine predictive power of updated frailty index Cut-off evaluation to confirm maintained association with Death and Serious Morbidity (DSM) Death and Serious Morbidity (DSM) 1. Mortality 2. Stroke (CVA) 3. Myocardial Infarction (MI) 4. Cardiac arrest with CPR 5. Pulmonary Embolism (PE) 6. Ventilator Dependence 7. Acute renal failure (ARF) 8. Sepsis 9. Septic Shock 10. Organ-space infection 11. Wound dehiscence

9 Deriving the Updated NSQIP Frailty Index 10 items from CSHA mapped to 14 NSQIP variables All were associated with DSM on univariable chi-squared analysis (p<0.001) Backwards stepwise multivariable regression identified the 9 most strongly associated variables. Points 1. ASA Class (IV or V) 4 2. Albumin <3.5mg/dl 2 3. Ascites in the prev 30d 2 4. Dep functional status 2 5. Chronic care transfer 2 6. Renal failure, on dialysis 2 7. History of COPD (Severe) 2 8. CHF exacerb in prev 30d 2 9. Disseminated Cancer 2

10 Calculating Updated Frailty Index Weighted product score based on odds ratios: Patient with dependent functional status and transferred from a chronic care facility and no other comorbidities 2 2 = 4 Patient with hypoalbuminemia, ASA Class (IV or V) and severe COPD = 16

11 Colectomy Development Sample Colectomy Validation Sample AUC (NFI): 0.72 ( ) AUC (Regression): 0.72 ( ) AUC (NFI): 0.71 ( )

12 Prevalence and DSM Rates in Colectomy Patients >16 Updated NSQIP Frailty Index

13 Most strongly associated with death and pulmonary adverse events Mortality Serious Morbidity Cardiovascular Pulmonary Any Infection Robust (NFI<8) Frail (NFI>=8) Percent p<0.001

14 Validation in Vascular Surgery Patients Prevalance DSM Rate >16 Updated NSQIP Frailty Index ROC Analysis AUC: 0.69 ( )

15 All Vascular Procedures (N=41,839 patients) Mortality Serious Morbidity Pulmonary AE Cardiovascular AE Any Infection Robust (NFI<8) Frail (NFI>8) p< Percent

16 Carotid Endarterectomy (N=13,775) MI/Arrythmia Stroke Cranial Nerve Injury Robust (NFI<8) Frail (NFI>8) p<0.05 Revascularization Percent

17 Abdominal Aneurysm Repair (N=2,162) Robust (NFI<8) Frail (NFI>8) p<0.001 LE Ischemia Ischemic Colitis Percent

18 Lower Extremity Procedures (N=13,499) Major Amputation Untreated Loss of Patency Major Reintervention Robust (NFI<8) Frail (NFI>8) p< Percent

19 Conclusions Updated NSQIP FI: Simple Strongly correlated with poor operative outcomes in different populations, both technical and non-technical Potential Uses: Rapid initial screening for more comprehensive assessments Retrospective institutional reviews to assess the impact of frailty on local populations.

20 Acknowledgements Our Patients ACS NSQIP Henry Pitt, MD Scott Cowan, MD Kristine Swartz, MD Susan Parks, MD