“…frail patients have better outcomes when operated on in centers caring for a higher volume of these patients…”

Image: © ThinkStock.

Image: © ThinkStock.

FOR the management of many medical conditions, such as stroke or myocardial infarction, high-volume centers tend to have better outcomes than low-volume centers.1,2  This appears to be related to experience gained over time and associated services and infrastructure. Such volume–outcome relationships are also well established for surgical procedures, such as cardiac surgery, where a combination of surgical experience and protocolized care pathways are important for optimal outcomes.3  In recent years, frailty—a state of diminished physiologic reserve leading to vulnerability and propensity for adverse outcomes—has become a focus of attention for many patient groups.4  For surgical patients, a state of preoperative frailty has been shown to be an important predictor of postoperative mortality, hospital length of stay, and discharge to long-term care institutions.5,6  These patients may have their own specific care needs after surgery, such as requirements for more aggressive physical therapy, or increased risk of adverse reactions to polypharmacy. If we, therefore, consider frailty as a pathologic state with its own specific care needs, centers that care for a higher volume of frail patients may provide better or more comprehensive care geared for this patient group, leading to better outcomes. In this issue of Anesthesiology, McIsaac et al.7  present the results of a population-level retrospective study, assessing the volume–outcome relationship for frail patients undergoing moderate- to high-risk surgical procedures in Ontario.

The authors included all adult patients having selected surgeries between 2002 and 2014 and identified those in a frailty state using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicators.8  They stratified the frail patients into five groups based on the volume of frail surgical patients cared for in the hospital where the surgery took place. It is important to note that they did not restrict their population to only elderly patients, recognizing that a frail state can occur in younger individuals as well.9  The results showed a higher risk of death and failure to rescue when frail patients were operated on in centers with an overall low volume of frail surgical patients. Moreover, they found that there appeared to be a threshold effect above which higher volumes were not associated with better outcomes. The authors were also careful to distinguish their finding of a volume–outcome relationship for frail patients from more general volume–outcome relationships; postoperative outcomes were not associated with the total hospital surgical volume, but rather with the volume of frail surgical patients seen at each center. Overall, the findings of this study are an important first step toward elucidating best care options for frail patients who require surgery.

More than a dozen frailty assessment tools have been described, and there is no consensus on which are best.10  Furthermore, scales like the Clinical frailty scale11  and the Fried phenotype12  require direct patient contact. Identifying frailty status using administrative data remains a challenging task. The John Hopkins Adjusted Clinical Groups index, used in this study, is a validated tool based on the diagnosis of geriatric syndromes from previous health encounters, such as weight loss, falls, and malnutrition. This use of a validated tool is a strength of the study. However, the limitation is that studies comparing different instruments (even validated ones) in the same cohort show moderate agreement at best.13 

The results of the study by McIsaac et al.7  support the hypothesis that frail patients have better outcomes when operated on in centers caring for a higher volume of these patients but were unable to identify contributing factors. We can speculate that patients suffering from repetitive falls or urinary incontinence need focused evaluations and interventions to optimize postoperative care. The input and care provided by physiotherapists, nutritionists, and other healthcare professionals—individuals who often make up specialist geriatrics teams—are likely important for these patients. While many surgical procedures were included, most patients had hip and knee replacements; these are two surgical procedures where high-quality rehabilitation and involvement of multidisciplinary care teams are already considered important.14  Hospitals that perform high volumes of these particular surgeries may already have a culture of needs assessment and early intervention on their wards, and particularly postsurgery.

This study also raises important questions related to healthcare organization and policy. Identifying frailty at the individual patient level by prospectively screening patients is not generally part of the preoperative assessment in most institutions. As more studies identify the impact of frailty on outcomes, perhaps such assessments may become routine. Most importantly, should all patients identified as frail before surgery be transferred from low- to high-volume centers? And what cost-effective strategies might be implemented to improve outcomes in low-volume centers? More studies are clearly needed in this evolving area of frailty research in the surgical population.

Competing Interests

The authors are not supported by, nor maintain any financial interest in, any commercial activity that may be associated with the topic of this article.

References

References
1.
Grigoryan
M
,
Chaudhry
SA
,
Hassan
AE
,
Suri
FK
,
Qureshi
AI
:
Neurointerventional procedural volume per hospital in United States: Implications for comprehensive stroke center designation.
Stroke
2012
;
43
:
1309
14
2.
Kumbhani
DJ
,
Cannon
CP
,
Fonarow
GC
,
Liang
L
,
Askari
AT
,
Peacock
WF
,
Peterson
ED
,
Bhatt
DL
:
Association of hospital primary angioplasty volume in ST-segment elevation myocardial infarction with quality and outcomes.
JAMA
2009
;
302
:
2207
13
3.
Gonzalez
AA
,
Dimick
JB
,
Birkmeyer
JD
,
Ghaferi
AA
:
Understanding the volume-outcome effect in cardiovascular surgery: The role of failure to rescue.
JAMA Surg
2014
;
149
:
119
23
4.
Fulop
T
,
Larbi
A
,
Witkowski
JM
,
McElhaney
J
,
Loeb
M
,
Mitnitski
A
,
Pawelec
G
:
Aging, frailty and age-related diseases.
Biogerontology
2010
;
11
:
547
63
5.
Afilalo
J
,
Mottillo
S
,
Eisenberg
MJ
,
Alexander
KP
,
Noiseux
N
,
Perrault
LP
,
Morin
JF
,
Langlois
Y
,
Ohayon
SM
,
Monette
J
,
Boivin
JF
,
Shahian
DM
,
Bergman
H
:
Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity.
Circ Cardiovasc Qual Outcomes
2012
;
5
:
222
8
6.
Makary
MA
,
Segev
DL
,
Pronovost
PJ
,
Syin
D
,
Bandeen-Roche
K
,
Patel
P
,
Takenaga
R
,
Devgan
L
,
Holzmueller
CG
,
Tian
J
,
Fried
LP
:
Frailty as a predictor of surgical outcomes in older patients.
J Am Coll Surg
2010
;
210
:
901
8
7.
McIsaac
DI
,
Wijeysundera
DN
,
Huang
A
,
Bryson
GL
,
van Walraven
C
:
Association of the hospital volume of frail surgical patients cared for with outcomes after elective, major noncardiac surgery: A retrospective population-based cohort study.
Anesthesiology
2017
;
126
:
602
13
8.
Sternberg
SA
,
Bentur
N
,
Abrams
C
,
Spalter
T
,
Karpati
T
,
Lemberger
J
,
Heymann
AD
:
Identifying frail older people using predictive modeling.
Am J Manag Care
2012
;
18
:
e392
7
9.
Bagshaw
SM
,
Stelfox
HT
,
McDermid
RC
,
Rolfson
DB
,
Tsuyuki
RT
,
Baig
N
,
Artiuch
B
,
Ibrahim
Q
,
Stollery
DE
,
Rokosh
E
,
Majumdar
SR
:
Association between frailty and short- and long-term outcomes among critically ill patients: A multicentre prospective cohort study.
CMAJ
2014
;
186
:
E95
102
10.
de Vries
NM
,
Staal
JB
,
van Ravensberg
CD
,
Hobbelen
JS
,
Olde Rikkert
MG
,
Nijhuis-van der Sanden
MW
:
Outcome instruments to measure frailty: A systematic review.
Ageing Res Rev
2011
;
10
:
104
14
11.
Rockwood
K
,
Song
X
,
MacKnight
C
,
Bergman
H
,
Hogan
DB
,
McDowell
I
,
Mitnitski
A
:
A global clinical measure of fitness and frailty in elderly people.
CMAJ
2005
;
173
:
489
95
12.
Fried
LP
,
Tangen
CM
,
Walston
J
,
Newman
AB
,
Hirsch
C
,
Gottdiener
J
,
Seeman
T
,
Tracy
R
,
Kop
WJ
,
Burke
G
,
McBurnie
MA
;
Cardiovascular Health Study Collaborative Research Group
:
Frailty in older adults: Evidence for a phenotype.
J Gerontol A Biol Sci Med Sci
2001
;
56
:
M146
56
13.
Cigolle
CT
,
Ofstedal
MB
,
Tian
Z
,
Blaum
CS
:
Comparing models of frailty: The Health and Retirement Study.
J Am Geriatr Soc
2009
;
57
:
830
9
14.
Dy
CJ
,
Dossous
PM
,
Ton
QV
,
Hollenberg
JP
,
Lorich
DG
,
Lane
JM
:
Does a multidisciplinary team decrease complications in male patients with hip fractures?
Clin Orthop Relat Res
2011
;
469
:
1919
24