Association of preoperative anaesthesia consultation prior to elective noncardiac surgery with patient and health system outcomes: a population-based study.

BACKGROUND: Surgical volumes and use of preoperative anaesthesia consultations are increasing. However, contemporary data estimating the association between preoperative anaesthesia consultation and patient (days alive and at home [DAH30], mortality) and system (costs, length of stay, and readmissions) outcomes are not available. METHODS: We conducted a population-based comparative effectiveness study using linked health administrative data among patients aged ≥40 yr who underwent intermediate-risk to high-risk elective, inpatient, noncardiac surgery in Ontario, Canada (2009-17). Our primary outcome was DAH30. Secondary outcomes included DAH90, 30-day and 1-yr mortality, 30-day health system costs, length of index admission, and 30-day readmissions. Propensity score overlap weights were used to adjust for confounders. Prespecified effect modifier analyses focused on high-risk subgroups. RESULTS: Among 364 149 patients, 274 365 (75.3%) received a preoperative anaesthesia consultation. No adjusted association was found (22.5 days vs 22.5 days; adjusted ratio of means 1.00, 95% CI 1.00-1.00) between consultation and DAH30 in the full population. We identified significant effect modification (significantly more DAH30) among patients with ischaemic heart disease, ASA physical status ≥4, frailty index score ≥0.21, and who underwent vascular surgery. Secondary outcomes were associated with preoperative consultation, including greater DAH90, decreased length of stay, lower 30-day and 1-yr mortality, and reduced 30-day costs. CONCLUSIONS: Preoperative anaesthesia consultation was not associated with greater DAH30 across the overall study population. However, important potential benefits were observed among high-risk subgroups. Research is needed to identify optimal patient populations and consultation processes.

A model to predict level of adherence to prehabilitation in older adults with frailty having cancer surgery.

PURPOSE: Preoperative exercise could improve postoperative outcomes for people with frailty; however, little is known about how to predict older people's adherence to exercise before surgery (i.e., prehabilitation) programs. Our objective was to derive and validate a model to predict prehabilitation adherence in older adults living with frailty before cancer surgery. METHODS: This was a nested prospective cohort study of older adults with frailty having cancer surgery who participated in a randomized controlled trial of home-based prehabilitation compared with standard perioperative care. We constructed a multivariable ordinary least squares linear regression model to predict adherence. Covariates were selected a priori based on clinical expertise and systematic review. Optimism was estimated through internal validation using bootstrap resampling. RESULTS: The derivation cohort consisted of 95 participants in the intervention arm of the trial. Percent adherence ranged from 0% to 100%, with a mean (standard deviation) of 61 (34)%. Previous physical activity and age were the only predictors significant at the 5% level. CONCLUSION: A prespecified multivariable model may help to explain a modest degree of variation in prehabilitation adherence in older people with frailty. While this model is an important step toward personalizing prehabilitation support, this study was limited by a small sample size and future research is needed to better understand personalized prediction of prehabilitation adherence in older people with frailty.

RéSUMé: OBJECTIF: L'exercice préopératoire pourrait améliorer les issues postopératoires pour les personnes fragilisées; cependant, on ne sait que peu de choses sur la façon de prédire l'observance des personnes âgées à faire de l'exercice avant leur chirurgie (c.-à-d. à suivre des programmes de préadaptation). Notre objectif était de définir et de valider un modèle pour prédire l'observance de la préadaptation chez les personnes âgées fragilisées avant une chirurgie oncologique. MéTHODE: Il s'agissait d'une étude de cohorte prospective imbriquée auprès de personnes âgées fragilisées subissant une chirurgie oncologique qui ont participé à une étude randomisée contrôlée sur la préadaptation à domicile par rapport aux soins périopératoires standard. Nous avons construit un modèle de régression linéaire des moindres carrés ordinaires multivariés pour prédire l'observance. Les covariables ont été sélectionnées a priori sur la base de notre expertise clinique et d'une revue systématique. L'optimisme a été estimé par validation interne à l'aide d'une méthode de rééchantillonnage type « bootstrap ¼. RéSULTATS: La cohorte de dérivation comprenait 95 participant·es dans le volet intervention de l'étude. Le pourcentage d'observance variait de 0 % à 100 %, avec une moyenne (écart type) de 61 (34) %. L'activité physique antérieure et l'âge étaient les seuls prédicteurs significatifs au seuil de 5 %. CONCLUSION: Un modèle multivarié prédéfini peut aider à expliquer un degré modeste de variation dans l'observance de la préadaptation chez les personnes âgées fragilisées. Bien que ce modèle soit une étape importante vers la personnalisation du soutien à la préadaptation, cette étude a été limitée par un échantillon de petite taille; des recherches futures sont nécessaires pour mieux comprendre la prédiction personnalisée de l'observance de la préadaptation chez les personnes âgées fragilisées.

Barriers and facilitators to participation in exercise prehabilitation before cancer surgery for older adults with frailty: a qualitative study.

BACKGROUND: Older adults with frailty are at an increased risk of adverse outcomes after surgery. Exercise before surgery (exercise prehabilitation) may reduce adverse events and improve recovery after surgery. However, adherence with exercise therapy is often low, especially in older populations. The purpose of this study was to qualitatively assess the barriers and facilitators to participating in exercise prehabilitation from the perspective of older people with frailty participating in the intervention arm of a randomized trial. METHODS: This was a research ethics approved, nested descriptive qualitative study within a randomized controlled trial of home-based exercise prehabilitation vs. standard care with older patients (≥ 60 years) having elective cancer surgery, and who were living with frailty (Clinical Frailty Scale ≥ 4). The intervention was a home-based prehabilitation program for at least 3 weeks before surgery that involved aerobic activity, strength and stretching, and nutritional advice. After completing the prehabilitation program, participants were asked to partake in a semi-structured interview informed by the Theoretical Domains Framework (TDF). Qualitative analysis was guided by the TDF. RESULTS: Fifteen qualitative interviews were completed. Facilitators included: 1) the program being manageable and suitable to older adults with frailty, 2) adequate resources to support engagement, 3) support from others, 4) a sense of control, intrinsic value, noticing progress and improving health outcomes and 5) the program was enjoyable and facilitated by previous experience. Barriers included: 1) pre-existing conditions, fatigue and baseline fitness, 2) weather, and 3) guilt and frustration when unable to exercise. A need for individualization and variety was offered as a suggestion by participants and was therefore described as both a barrier and facilitator. CONCLUSIONS: Home-based exercise prehabilitation is feasible and acceptable to older people with frailty preparing for cancer surgery. Participants identified that a home-based program was manageable, easy to follow with helpful resources, included valuable support from the research team, and they reported self-perceived health benefits and a sense of control over their health. Future studies and implementation should consider increased personalization based on health and fitness, psychosocial support and modifications to aerobic exercises in response to adverse weather conditions.

Polysomnographic Assessment of Sleep Disturbances in Cancer Development: A Historical Multicenter Clinical Cohort Study.

BACKGROUND: Many cellular processes are controlled by sleep. Therefore, alterations in sleep might be expected to stress biological systems that could influence malignancy risk. RESEARCH QUESTION: What is the association between polysomnographic measures of sleep disturbances and incident cancer, and what is the validity of cluster analysis in identifying polysomnography phenotypes? STUDY DESIGN AND METHODS: We conducted a retrospective multicenter cohort study using linked clinical and provincial health administrative data on consecutive adults free of cancer at baseline with polysomnography data collected between 1994 and 2017 in four academic hospitals in Ontario, Canada. Cancer status was derived from registry records. Polysomnography phenotypes were identified by k-means cluster analysis. A combination of validation statistics and distinguishing polysomnographic features was used to select clusters. Cox cause-specific regressions were used to assess the relationship between identified clusters and incident cancer. RESULTS: Among 29,907 individuals, 2,514 (8.4%) received a diagnosis of cancer over a median of 8.0 years (interquartile range, 4.2-13.5 years). Five clusters were identified: mild (mildly abnormal polysomnography findings), poor sleep, severe OSA or sleep fragmentation, severe desaturations, and periodic limb movements of sleep (PLMS). The associations between cancer and all clusters compared with the mild cluster were significant while controlling for clinic and year of polysomnography. When additionally controlling for age and sex, the effect remained significant only for PLMS (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.06-1.50) and severe desaturations (aHR, 1.32; 95% CI, 1.04-1.66). Further controlling for confounders, the effect remained significant for PLMS, but was attenuated for severe desaturations. INTERPRETATION: In a large cohort, we confirmed the importance of polysomnographic phenotypes and highlighted the role that PLMS and oxygenation desaturation may play in cancer. Using this study's findings, we also developed an Excel (Microsoft) spreadsheet (polysomnography cluster classifier) that can be used to validate the identified clusters on new data or to identify which cluster a patient belongs to. TRIAL REGISTRY: ClinicalTrials.gov; Nos.: NCT03383354 and NCT03834792; URL: www. CLINICALTRIALS: gov.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints.

BACKGROUND: As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS: A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room to physiotherapy assessment and from the operating room to discharge were recorded. These were referred to as ambulation time and discharge time, respectively. RESULTS: The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), and 227 minutes (range, 77 to 387), respectively-(P < .0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), and 371 minutes (range, 217 to 570), respectively-(P < .0001). No cases of transient neurologic symptoms were reported. CONCLUSION: Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is rapid and efficacious.

Identifying barriers and facilitators to routine preoperative frailty assessment: a qualitative interview study.

PURPOSE: Preoperative frailty assessment is recommended by multiple practice guidelines and may improve outcomes, but it is not routinely performed. The barriers and facilitators of routine preoperative frailty assessment have not been formally assessed. Our objective was to perform a theory-guided evaluation of barriers and facilitators to preoperative frailty assessment. METHODS: This was a research ethics board-approved qualitative study involving physicians who perform preoperative assessment (consultant and resident anesthesiologists and consultant surgeons). Semistructured interviews were conducted by a trained research assistant informed by the Theoretical Domains Framework to identify barriers and facilitators to frailty assessment. Interview transcripts were independently coded by two research assistants to identify specific beliefs relevant to each theoretical domain. RESULTS: We interviewed 28 clinicians (nine consultant anesthesiologists, nine consultant surgeons, and ten anesthesiology residents). Six domains (Knowledge [100%], Social Influences [96%], Social Professional Role and Identity [96%], Beliefs about Capabilities [93%], Goals [93%], and Intentions [93%]) were identified by > 90% of respondents. The most common barriers identified were prioritization of other aspects of assessment (e.g., cardio/respiratory) and a lack of awareness of evidence and guidelines supporting frailty assessment. The most common facilitators were a high degree of familiarity with frailty, recognition of the importance of frailty assessment, and strong intentions to perform frailty assessment. CONCLUSION: Barriers and facilitators to preoperative frailty assessment are multidimensional, but generally consistent across different types of perioperative physicians. Knowledge of barriers and facilitators can guide development of evidence-based strategies to increase frailty assessment.

RéSUMé: OBJECTIF: L'évaluation préopératoire de la fragilité est recommandée par plusieurs lignes directrices de pratique et pourrait améliorer les devenirs, mais elle n'est pas systématiquement réalisée. Les obstacles et les facilitateurs de l'évaluation de routine de la fragilité préopératoire n'ont pas été officiellement évalués. Notre objectif était de mener une évaluation théorique des obstacles et des facilitateurs de l'évaluation préopératoire de la fragilité. MéTHODE: Il s'agissait d'une étude qualitative approuvée par le comité d'éthique de la recherche impliquant des médecins menant des évaluations préopératoires (anesthésiologistes, résidents en anesthésiologie et chirurgiens). Des entrevues semi-structurées ont été réalisées par un assistant de recherche formé en se fondant sur le Cadre des domaines théoriques afin d'identifier les obstacles et les facilitateurs à l'évaluation de la fragilité. Les transcriptions des entrevues ont été codées de manière indépendante par deux assistants de recherche afin d'identifier les croyances spécifiques pertinentes à chaque domaine théorique. RéSULTATS: Nous avons interrogé 28 cliniciens (neuf anesthésiologistes, neuf chirurgiens et dix résidents en anesthésiologie). Six domaines (Connaissances [100 %], Influences sociales [96 %], Rôle et identité socio-professionnels [96 %], Croyances concernant les capacités [93 %], Objectifs [93 %] et Intentions [93 %]) ont été identifiés par > 90 % des répondants. Les obstacles les plus fréquemment cités étaient la priorisation accordée à d'autres aspects de l'évaluation (p. ex., cardio/respiratoire) et le manque de connaissances des données probantes et des lignes directrices à l'appui de l'évaluation de la fragilité. Les facilitateurs les plus courants étaient un degré élevé de familiarité avec la fragilité, la reconnaissance de l'importance de l'évaluation de la fragilité et de fortes intentions de réaliser une évaluation de la fragilité. CONCLUSION: Les obstacles et les facilitateurs de l'évaluation préopératoire de la fragilité sont multidimensionnels, mais généralement uniformes parmi les différents types de médecins périopératoires. La connaissance des obstacles et des facilitateurs peut guider l'élaboration de stratégies fondées sur des données probantes pour augmenter l'évaluation de la fragilité.

Home-based prehabilitation with exercise to improve postoperative recovery for older adults with frailty having cancer surgery: the PREHAB randomised clinical trial.

BACKGROUND: Frailty is a state of vulnerability as a result of decreased reserves. Prehabilitation may increase reserve and improve postoperative outcomes. Our objective was to determine if home-based prehabilitation improves postoperative functional recovery in older adults with frailty having cancer surgery. METHODS: This double blind randomised trial enrolled people ≥60 yr having elective cancer surgery and ≥3 weeks from enrolment to surgery as eligible. Participation in a remotely supported, home-based exercise prehabilitation program plus nutritional guidance was compared with standard care plus written advice on age-appropriate activity and nutrition. The primary outcome was 6-min walk test (6MWT) distance at the first postoperative clinic visit. Secondary outcomes included physical performance, quality of life, disability, length of stay, non-home discharge, and 30-day readmission. RESULTS: Of 543 patients assessed, 254 were eligible and 204 (80%) were randomised (102 per arm); 182 (94 intervention and 88 control) had surgery and were analysed. Mean age was 74 yr and 57% were female. Mean duration of participation was 5 weeks, mean adherence was 61% (range 0%-100%). We found no significant difference in 6MWT at follow-up (+14 m, 95% confidence interval -26-55 m, P=0.486), or for secondary outcomes. Analyses using a prespecified adherence definition of ≥80% supported improvements in 6MWT distance, complication count, and disability. CONCLUSIONS: A home-based prehabilitation program did not significantly improve postoperative recovery or other outcomes in older adults with frailty having cancer surgery. Program adherence may be a key mediator of prehabilitation efficacy. CLINICAL TRIAL REGISTRATION: NCT02934230.

Development and evaluation of an evidence-based, theory-grounded online Clinical Frailty Scale tutorial.

INTRODUCTION: Frailty is a robust predictor of adverse outcomes in older people. Practice guidelines recommend routine screening for frailty; however, this does not occur regularly. The Clinical Frailty Scale (CFS) is a validated, feasible instrument that can be used in a variety of clinical settings and is associated with many adverse outcomes. Our objective was to develop and evaluate an online training module to guide frailty assessment using the CFS. METHODS: A multidisciplinary team of clinical experts developed an evidence-based, theory-grounded online training module for users who wished to perform frailty assessment using the CFS. The module was prospectively evaluated for user satisfaction, effectiveness and feasibility using a standardised questionnaire. Qualitative feedback was analysed with thematic analysis. RESULTS: Version 1 of the CFS module was used 627 times from 21 October 2019 to 24 March 2020. Satisfaction, effectiveness and feasibility of the module were positively rated (≥4/5 on a 5-point Likert scale n = 582 [93%], n = 507, [81%], n = 575, [91%], respectively). Qualitative feedback highlighted ease of use, likelihood of users to share the module with others and opportunities to increase multimedia content. CONCLUSION: An online tutorial, designed using evidence and theory to guide frailty assessment using the CFS, was positively rated by users. The module's content and structure was rated effective and feasible, and users were satisfied with, and likely to share, the module. Research evaluating the module's impact on the accuracy of frailty assessment is required.

Polysomnographic Markers of Obstructive Sleep Apnea Severity and Cancer-related Mortality: A Large Retrospective Multicenter Clinical Cohort Study.

Rationale: The evidence for an association between cancer survival and obstructive sleep apnea (OSA) remains underexplored. Objectives: To evaluate an association between markers of OSA severity (respiratory disturbances, hypoxemia, and sleep fragmentation) and cancer-related mortality in individuals with previously diagnosed cancer. Methods: We conducted a multicenter retrospective cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four Canadian academic hospitals and were previously diagnosed with cancer through the Ontario Cancer Registry. Multivariable cause-specific Cox regressions were used to address the research objective. Results: We included 2,222 subjects. Over a median follow-up time of 5.6 years (interquartile range [IQR], 2.7-9.1 years), 261/2,222 (11.7%) individuals with prevalent cancer died from cancer-related causes, which accounted for 44.2% (261/590) of all-cause death. Controlling for age, sex, alcohol use disorder, prior heart failure, chronic obstructive pulmonary disease, hypertension, diabetes, treatment for OSA, clinic site, year of the sleep study, and time since the cancer diagnosis, measures of hypoxemia and sleep fragmentation, but not apnea-hypopnea index, were significantly associated with the cancer-specific mortality: percentage of time spent with arterial oxygen saturation (SaO2) < 90% (hazard ratio [HR] per 5% increase, 1.05; 95% confidence interval, 1.01-1.09); mean SaO2 (HR per 3% increase, 0.79; 0.68-0.92); and percentage of stage 1 sleep (HR per 16% increase, 1.27; 1.07-1.51). Conclusions: In a large clinical cohort of adults with suspected OSA and previously diagnosed cancer, measures of nocturnal hypoxemia and sleep fragmentation as markers of OSA severity were significantly associated with cancer-related mortality, suggesting the need for more targeted risk awareness.

Complications as a Mediator of the Perioperative Frailty-Mortality Association.

BACKGROUND: Preoperative frailty is strongly associated with postoperative complications and mortality. However, the pathways between frailty, postoperative complications, and mortality are poorly described. The authors hypothesized that the occurrence of postoperative complications would mediate a substantial proportion of the total effect of frailty on mortality after elective noncardiac surgery. METHODS: Following protocol registration, the authors conducted a retrospective cohort study of intermediate- to high-risk elective noncardiac surgery patients (2016) using National Surgical Quality Improvement Program data. The authors conducted Bayesian mediation analysis of the relationship between preoperative frailty (exposure, using the Risk Analysis Index), serious complications (mediator), and 30-day mortality (outcome), comprehensively adjusting for confounders. The authors estimated the total effect of frailty on mortality (composed of the indirect effect mediated by complications and the remaining direct effect of frailty) and estimated the proportion of the frailty-mortality association mediated by complications. RESULTS: The authors identified 205,051 patients; 1,474 (0.7%) died. Complications occurred in 20,211 (9.9%). A 2 SD increase in frailty score resulted in a total association with mortality equal to an odds ratio of 3.79 (95% credible interval, 2.48 to 5.64), resulting from a direct association (odds ratio, 1.76; 95% credible interval, 1.34 to 2.30) and an indirect association mediated by complications (odds ratio, 2.15; 95% credible interval, 1.58 to 2.96). Complications mediated 57.3% (95% credible interval, 40.8 to 73.8) of the frailty-mortality association. Cardiopulmonary complications were the strongest mediators among complication subtypes. CONCLUSIONS: Complications mediate more than half of the association between frailty and postoperative mortality in elective noncardiac surgery.

Obstructive Sleep Apnea and Incident Cancer: A Large Retrospective Multicenter Clinical Cohort Study.

BACKGROUND: To examine the association between the severity of obstructive sleep apnea (OSA) and nocturnal hypoxemia with incident cancer. METHODS: This was a multicenter retrospective clinical cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four academic hospitals (Canada) who were free of cancer at baseline. Cancer status was derived from the Ontario Cancer Registry. Cox cause-specific regressions were utilized to address the objective and to calculate the 10-year absolute risk difference (ARD) in the marginal probability of incident cancer and the number needed to harm (NNH). RESULTS: Of 33,997 individuals considered, 33,711 with no missing OSA severity were included: median age, 50 years; 58% male; and 23% with severe OSA (apnea-hypopnea index >30). Of the 18,458 individuals with information on sleep time spent with oxygen saturation (SaO2) <90%, 5% spent >30% of sleep with SaO2 <90% (severe nocturnal hypoxemia). Over a median of 7 years, 2,498 of 33,711 (7%) individuals developed cancer, with an incidence rate of 10.3 (10.0-10.8) per 1,000 person-years. Controlling for confounders, severe OSA was associated with a 15% increased hazard of developing cancer compared with no OSA (HR = 1.15, 1.02-1.30; ARD = 1.28%, 0.20-2.37; and NNH = 78). Severe hypoxemia was associated with about 30% increased hazard (HR = 1.32, 1.08-1.61; ARD = 2.38%, 0.47-4.31; and NNH = 42). CONCLUSIONS: In a large cohort of individuals with suspected OSA free of cancer at baseline, the severity of OSA and nocturnal hypoxemia was independently associated with incident cancer. IMPACT: These findings suggest the need for more targeted cancer risk awareness in individuals with OSA.

Evaluation of a preoperative personalized risk communication tool: a prospective before-and-after study.

PURPOSE: Patients want personalized information before surgery; most do not receive personalized risk estimates. Inadequate information contributes to poor experience and medicolegal complaints. We hypothesized that exposure to the Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment (PREDICT) app, a personalized risk communication tool, would improve patient knowledge and satisfaction after anesthesiology consultations compared with standard care. METHODS: We conducted a prospective clinical study (before-after design) and used patient-reported data to calculate personalized risks of morbidity, mortality, and expected length of stay using a locally calibrated National Surgical Quality Improvement Program risk calculator embedded in the PREDICT app. In the standard care (before) phase, the application's materials and output were not available to participants; in the PREDICT app (after) phase, personalized risks were communicated. Our primary outcome was knowledge score after the anesthesiology consultation. Secondary outcomes included patient satisfaction, anxiety, feasibility, and acceptability. RESULTS: We included 183 participants (90 before; 93 after). Compared with standard care phase, the PREDICT app phase had higher post-consultation: knowledge of risks (14.3% higher; 95% confidence interval [CI], 6.5 to 22.0; P < 0.001) and satisfaction (0.8 points; 95% CI, 0.1 to 1.4; P = 0.03). Anxiety was unchanged (- 1.9%; 95% CI, - 4.2 to 0.5; P = 0.13). Acceptability was high for patients and anesthesiologists. CONCLUSION: Exposure to a patient-facing, personalized risk communication app improved knowledge of personalized risk and increased satisfaction for adults before elective inpatient surgery. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03422133); registered 5 February 2018.

RéSUMé: OBJECTIF: Les patients veulent disposer d'informations personnalisées avant leur chirurgie, mais la plupart d'entre eux ne reçoivent pas d'estimations de leur risque personnalisées. Des informations inadéquates contribuent à une mauvaise expérience et à des plaintes médicolégales. Nous avons émis l'hypothèse qu'une exposition à l'application PREDICT (Personalized Risk Evaluation and Decision Making in Preoperative Clinical Assessment), un outil de communication du risque personnalisé, améliorerait les connaissances et la satisfaction des patients après leurs consultations en anesthésiologie comparativement à des soins standard. MéTHODE: Nous avons réalisé une étude clinique prospective (de type avant-après) et utilisé les données rapportées par les patients afin de calculer leur risque personnalisé de morbidité et de mortalité, ainsi que la durée de séjour anticipée à l'aide d'un calculateur de risque tiré du Programme national d'amélioration de la qualité chirurgicale que nous avons calibré localement et intégré à l'application PREDICT. Dans la phase de soins standard (avant), le contenu et les résultats de l'application n'étaient pas divulgués aux participants; dans la phase comportant l'application PREDICT (après), les risques personnalisés étaient communiqués. Notre critère d'évaluation principal était le score des connaissances des patients après la consultation en anesthésiologie. Les critères d'évaluation secondaires comprenaient la satisfaction des patients et leur niveau d'anxiété ainsi que la faisabilité et l'acceptabilité d'une telle approche. RéSULTATS: Nous avons inclus 183 participants (90 avant; 93 après). Comparativement à la phase de soins standard, la phase avec l'application PREDICT a démontré un niveau plus élevé de connaissances des risques post consultation (14,3 % plus élevé; intervalle de confiance [IC] 95 %, 6,5 à 22,0; P < 0,001) et de satisfaction (0,8 point; IC 95 %, 0,1 à 1,4; P = 0,03). L'anxiété est demeurée inchangée (− 1,9 %; IC 95 %, − 4,2 à 0,5; P = 0,13). L'acceptabilité était élevée, tant chez les patients que chez les anesthésiologistes. CONCLUSION: L'exposition des patients à une application de communication du risque personnalisé a amélioré leurs connaissances de leur risque personnalisé et augmenté la satisfaction des adultes avant une chirurgie non urgente et non ambulatoire. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03422133); enregistrée le 5 février 2018.

Frailty and long-term postoperative disability trajectories: a prospective multicentre cohort study.

BACKGROUND: Frailty is associated with early postoperative outcomes. How frailty influences long-term postoperative recovery is poorly described. Our objective was to evaluate the association of frailty with postoperative disability trajectories in the year after surgery. METHODS: Prespecified 1-yr follow-up of a prospective multicentre cohort study. Patients ≥65 yr were assessed for frailty before major elective noncardiac surgery (Clinical Frailty Scale [CFS] and Fried Phenotype [FP]). The primary outcome was patient-reported disability score (using the WHO Disability Assessment Schedule 2.0) at baseline, 30, 90, and 365 days after surgery. Repeated measures linear regression estimated the association of preoperative frailty with changes in disability scores over time, adjusted for procedure. Group-based trajectory modelling was used to identify subgroup trajectories of people with frailty. RESULTS: One-year follow-up was complete for 687/702 (97.9%) participants. Frailty was associated with a significant difference in disability trajectory (P<0.0001). Compared with baseline, people with frailty experienced a decrease in disability score at 365 days (CFS frailty: -7.3 points, 95% confidence interval [CI] -10.2 to -4.5); (FP frailty: -5.4 points, 95% CI -8.5 to -2.3); people without frailty had no significant change in their disability score from baseline (no CFS frailty: +0.8 points, 95% CI -1.7 to 3.2; no FP frailty: +1.1 points, 95% CI -3.5 to 1.3). More than one-third of people with frailty experienced an early increase in disability before achieving a net decrease in disability. CONCLUSIONS: Decision-making and care planning should integrate the possible trade-offs between early adverse outcomes with longer-term benefit when frailty is present in older surgical patients.

Logging in: a comparative analysis of electronic health records versus anesthesia resident-driven logbooks.

PURPOSE: Resident logbooks (RLBs) documenting clinical case exposure are widespread in medical education despite evidence of poor accuracy. Electronic health records (e.g., anesthesia information management systems [AIMS]) may provide advantages for auditing longitudinal case exposure. We evaluated the agreement between AIMS and RLBs for tracking case exposure during anesthesiology residency. METHODS: We performed a historical cohort study with anesthesiology residents (2011-2018, all of whom used a RLB contemporaneously with AIMS) working in a multisite academic health sciences network. The primary outcome was total case-load logging; secondary outcomes were volumes for seven surgical specialties (general, gynecology, neuro, orthopedic, thoracic, urology, and vascular surgery). Correlation of case numbers tracked by AIMS vs RLB was assessed using Pearson correlation; agreement was determined using Bland-Altman plots and intraclass correlation coefficients (ICC). RESULTS: Data from 27 anesthesiology residents were collected. Overall, mean (standard deviation) case numbers were generally greater with AIMS vs RLB [649 (103) vs 583 (191); P = 0.049). Total case volumes between systems had moderate correlation (r = 0.50) and agreement (intraclass correlation coefficient [ICC], 0.42; 95% CI, 0.34 to 0.59). Bland-Altman plots showed variable agreement between AIMS and RLB data [mean (SD) bias = 66 (166) cases]. For general, gynecology, neuro, orthopedic, thoracic, urology, and vascular surgery, there was a range of poor to moderate agreement (ICC, 0.23-0.57) between AIMS and RLB. CONCLUSION: For anesthesiology resident case-logging, the number of cases logged in an AIMS was higher with lower variance compared with RLBs. Anesthesia information management systems vs RLB data showed low-moderate correlation and agreement. Given the additional time and resources required for RLBs, AIMS may be a superior method for tracking cases where available.

RéSUMé: OBJECTIF: Les logbooks des résidents documentant leur exposition à des cas cliniques sont répandus dans la formation médicale et ce, malgré des données probantes déplorant leur manque de précision. Les dossiers médicaux informatisés (par ex., les systèmes de gestion de l'information en anesthésie [SGIA]) pourraient présenter des avantages pour le contrôle de l'exposition longitudinale des résidents aux cas. Notre étude a évalué la concordance entre les SGIA et les logbooks pour l'exposition aux cas pendant la résidence en anesthésiologie. MéTHODE: Nous avons réalisé une étude de cohorte historique auprès de résidents en anesthésiologie (2011­2018, tous les résidents ayant utilisé un logbook simultanément aux SGIA) travaillant dans un réseau universitaire de sciences de la santé multisite. Le critère d'évaluation principal était l'enregistrement du nombre de cas total; les critères d'évaluation secondaires comprenaient les volumes pour sept spécialités chirurgicales (soit la chirurgie générale, gynécologique, orthopédique, thoracique, urologique, vasculaire et la neurochirurgie). La corrélation entre le nombre de cas enregistrés dans les SGIA vs les logbooks a été évaluée à l'aide d'une corrélation de Pearson; l'agrément a été déterminé à l'aide d'un graphique de Bland­Altman et de coefficients de corrélation intraclasse (CCI). RéSULTATS: Les données de 27 résidents en anesthésiologie ont été colligées. Globalement, les nombres de cas moyens (écart type) étaient en général plus élevés dans les SGIA que dans les logbooks [649 (103) vs 583 (191); P = 0,049). Les volumes de cas totaux entre les systèmes présentaient une corrélation (r = 0,50) et un agrément (coefficient de corrélation intraclasse [CCI], 0,42; IC 95 %, 0,34 à 0,59) modérés. Les graphiques de Bland­Altman ont démontré un agrément variable entre les données des SGIA et celles des logbooks [biais moyen (ÉT) = 66 (166) cas]. Pour les chirurgies générales, gynécologiques, orthopédiques, thoraciques, urologique, vasculaires et neurochirurgies, l'agrément allait de faible à modéré (CCI, 0,23-0,57) entre les SGIA et les logbooks. CONCLUSION: En ce qui a trait à l'enregistrement des cas des résidents en anesthésiologie, le nombre de cas enregistrés dans un SGIA était plus élevé et présentait une variance moindre que dans les logbooks. Les données des systèmes de gestion de l'information en anesthésie vs des logbooks ont affiché une corrélation et un agrément faible à modéré. Étant donné le temps et les ressources supplémentaires nécessaires pour compléter les logbooks, les SGIA pourraient constituer une méthode supérieure pour le suivi des cas, lorsqu'un tel système est disponible.

Frailty as a Predictor of Death or New Disability After Surgery: A Prospective Cohort Study.

OBJECTIVE: To compare the accuracy of the modified Fried Index (mFI) and the Clinical Frailty Scale (CFS) to predict death or patient-reported new disability 90 days after major elective surgery. BACKGROUND: The association of frailty with patient-reported outcomes, and comparisons between preoperative frailty instruments are poorly described. METHODS: This was a prospective multicenter cohort study. We determined frailty status in individuals ≥65 years having elective noncardiac surgery using the mFI and CFS. Outcomes included death or patient-reported new disability (primary); safety incidents, length of stay (LOS), and institutional discharge (secondary); ease of use, usefulness, benefit, clinical importance, and feasibility (tertiary). We measured the adjusted association of frailty with outcomes using regression analysis and compared true positive and false positive rates (TPR/FPR). RESULTS: Of 702 participants, 645 had complete follow up. The CFS identified 297 (42.3%) with frailty, the mFI 257 (36.6%); 72 (11.1%) died or experienced a new disability. Frailty was significantly associated with the primary outcome (CFS adjusted odds ratio, OR, 2.51, 95% confidence interval, CI, 1.50-4.21; mFI adjusted-OR 2.60, 95% CI 1.57-4.31). TPR and FPR were not significantly different between instruments. Frailty was the only significant predictor of death or new disability in a multivariable analysis. Need for institutional discharge, costs and LOS were significantly increased in individuals with frailty. The CFS was easier to use, required less time and had less missing data. CONCLUSIONS: Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher.

Prospective Comparison of Preoperative Predictive Performance Between 3 Leading Frailty Instruments.

BACKGROUND: Guidelines recommend routine preoperative frailty assessment for older people. However, the degree to which frailty instruments improve predictive accuracy when added to traditional risk factors is poorly described. Our objective was to measure the accuracy gained in predicting outcomes important to older patients when adding the Clinical Frailty Scale (CFS), Fried Phenotype (FP), or Frailty Index (FI) to traditional risk factors. METHODS: This was an analysis of a multicenter prospective cohort of elective noncardiac surgery patients ≥65 years of age. Each frailty instrument was prospectively collected. The added predictive performance of each frailty instrument beyond the baseline model (age, sex, American Society of Anesthesiologists' score, procedural risk) was estimated using likelihood ratio test, discrimination, calibration, explained variance, and reclassification. Outcomes analyzed included death or new disability, prolonged length of stay (LoS, >75th percentile), and adverse discharge (death or non-home discharge). RESULTS: We included 645 participants (mean age, 74 [standard deviation, 6]); 72 (11.2%) participants died or experienced a new disability, 164 (25.4%) had prolonged LoS, and 60 (9.2%) had adverse discharge. Compared to the baseline model predicting death or new disability (area under the curve [AUC], 0.67; R, 0.08, good calibration), prolonged LoS (AUC, 0.73; R, 0.18, good calibration), and adverse discharge (AUC, 0.78; R, 0.16, poor calibration), the CFS improved fit per the likelihood ratio test (P < .02 for death or new disability, <.001 for LoS, <.001 for discharge), discrimination (AUC = 0.71 for death or new disability, 0.76 for LoS, 0.82 for discharge), calibration (good for death or new disability, LoS, and discharge), explained variance (R = 0.11 for death or new disability, 0.22 for LoS, 0.25 for discharge), and reclassification (appropriate directional reclassification) for all outcomes. The FP improved discrimination and R for all outcomes, but to a lesser degree than the CFS. The FI improved discrimination for death or new disability and R for all outcomes, but to a lesser degree than the CFS and the FP. These results were consistent in internal validation. CONCLUSIONS: Frailty instruments provide meaningful increases in accuracy when predicting postoperative outcomes for older people. Compared to the FP and FI, the CFS appears to improve all measures of predictive performance to the greatest extent and across outcomes. Combined with previous research demonstrating that the CFS is easy to use and requires less time than the FP, clinicians should consider its use in preoperative practice.

A Population-based Comparative Effectiveness Study of Peripheral Nerve Blocks for Hip Fracture Surgery.

BACKGROUND: Adverse outcomes and resource use rates are high after hip fracture surgery. Peripheral nerve blocks could improve outcomes through enhanced analgesia and decreased opioid related adverse events. We hypothesized that these benefits would translate into decreased resource use (length of stay [primary outcome] and costs), and better clinical outcomes (pneumonia and mortality). METHODS: The authors conducted a retrospective cohort study of hip fracture surgery patients in Ontario, Canada (2011 to 2015) using linked health administrative data. Multilevel regression, instrumental variable, and propensity scores were used to determine the association of nerve blocks with resource use and outcomes. RESULTS: The authors identified 65,271 hip fracture surgery patients; 10,030 (15.4%) received a block. With a block, the median hospital stay was 7 (interquartile range, 4 to 13) days versus 8 (interquartile range, 5 to 14) days without. Following adjustment, nerve blocks were associated with a 0.6-day decrease in length of stay (95% CI, 0.5 to 0.8). This small difference was consistent with instrumental variable (1.1 days; 95% CI, 0.9 to 1.2) and propensity score (0.2 days; 95% CI, 0.2 to 0.3) analyses. Costs were lower with a nerve block (adjusted difference, -$1,421; 95% CI, -$1,579 to -$1,289 [Canadian dollars]), but no difference in mortality (adjusted odds ratio, 0.99; 95% CI, 0.89 to 1.11) or pneumonia (adjusted odds ratio, 1.01; 95% CI, 0.88 to 1.16) was observed. CONCLUSIONS: Receipt of nerve blocks for hip fracture surgery is associated with decreased length of stay and health system costs, although small effect sizes may not reflect clinical significance for length of stay.