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BACKGROUND/OBJECTIVES: Obesity is a global health challenge that affects a large proportion of adults worldwide. Obesity and frailty pose considerable health risks due to their potential to interact and amplify one another's negative effects. Therefore, we sought to compare the discriminatory thresholds of the risk analysis index (RAI), 5-factor modified frailty index (m-FI-5) and patient age for the primary endpoint of postoperative mortality. SUBJECTS/METHODS: We included spine surgery patients ≥18 years old, from the American College of Surgeons National Quality Improvement program database from 2012-2020, that were classified as obese. We performed receiver operating characteristic curve analysis to compare the discrimination threshold of RAI, mFI-5, and patient age for postoperative mortality. Proportional hazards risk-adjusted regressions were performed, and Hazard ratios and corresponding 95% Confidence intervals (CI) are reported. RESULTS: Overall, there were 149 163 patients evaluated, and in the ROC analysis for postoperative mortality, RAI showed superior discrimination C-statistic 0.793 (95%CI: 0.773-0.813), compared to mFI-5 C-statistic 0.671 (95%CI 0.650-0.691), and patient age C-statistic 0.686 (95%CI 0.666-0.707). Risk-adjusted analyses were performed, and the RAI had a stepwise increasing effect size across frailty strata: typical patients HR 2.55 (95%CI 2.03-3.19), frail patients HR 3.48 (95%CI 2.49-4.86), and very frail patients HR 4.90 (95%CI 2.87-8.37). We found increasing postoperative mortality effect sizes within Clavein-Dindo complication strata, consistent across obesity categories, exponentially increasing with frailty, and multiplicatively enhanced within CD, frailty and obesity strata. CONCLUSION: In this study of 149 163 patients classified as obese and undergoing spine procedures in an international prospective surgical database, the RAI demonstrated superior discrimination compared to the mFI-5 and patient age in predicting postoperative mortality risk. The deleterious effects of frailty and obesity were synergistic as their combined effect predicted worse outcomes.
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Fragilidad , Adulto , Humanos , Adolescente , Fragilidad/complicaciones , Estudios Prospectivos , Medición de Riesgo/métodos , Obesidad/complicaciones , Curva ROC , Complicaciones Posoperatorias , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Quality measures determine reimbursement rates and penalties in value-based payment models. Frailty impacts these quality metrics across surgical specialties. We compared the discriminatory thresholds for the risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for the outcomes of extended length of stay (LOS [eLOS]), prolonged LOS within 30 days (pLOS), and protracted LOS (LOS > 30). METHODS: Patients ≥18 years old who underwent neurosurgical procedures between 2012 and 2020 were queried from the ACS-NSQIP. We performed receiver operating characteristic analysis, and multivariable analyses to examine discriminatory thresholds and identify independent associations. RESULTS: There were 411,605 patients included, with a median age of 59 years (IQR, 48-69), 52.2% male patients, and a white majority 75.2%. For eLOS: RAI C-statistic 0.653 (95% CI: 0.652-0.655), versus mFI-5 C-statistic 0.552 (95% CI: 0.550-0.554) and increasing patient age C-statistic 0.573 (95% CI: 0.571-0.575). Similar trends were observed for pLOS- RAI: 0.718, mFI-5: 0.568, increasing patient age: 0.559, and for LOS>30- RAI: 0.714, mFI-5: 0.548, and increasing patient age: 0.506. Patients with major complications had eLOS 10.1%, pLOS 26.5%, and LOS >30 45.5%. RAI showed a larger effect for all three outcomes, and major complications in multivariable analyses. CONCLUSION: Increasing frailty was associated with three key quality metrics that is, eLOS, pLOS, LOS > 30 after neurosurgical procedures. The RAI demonstrated a higher discriminating threshold compared to both mFI-5 and increasing patient age. Preoperative frailty screening may improve quality metrics through risk mitigation strategies and better preoperative communication with patients and their families.
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Fragilidad , Tiempo de Internación , Procedimientos Neuroquirúrgicos , Humanos , Persona de Mediana Edad , Masculino , Femenino , Fragilidad/diagnóstico , Anciano , Tiempo de Internación/estadística & datos numéricos , Medición de Riesgo , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud , Estudios Retrospectivos , Adulto , Factores de EdadRESUMEN
BACKGROUND: Neurological surgery remains one of the most competitive specialties with a match rate of <70%. Historically, medical student performance was gauged through the USMLE Step 1. However, with the recent exam score change, metrics such as recommendation letters, research, and clerkship grades carry increased importance. Research experiences vary greatly between institutions and medical students depend on faculty/resident mentorship in order to facilitate scholarly activity. We previously reported our 2-year intensive research initiative (IRI) in a neurosurgery program. Here we report successful implementation of the IRI in a disparate setting, a department devoid of residents, and demonstrate the IRI's reproducibility with non-resident learners. MATERIALS & METHODS: We compared retrospective data from 2007 to 2020 with the IRI's results during the 2-year study period (July 2020-July 2022). RESULTS: The IRI resulted in a rapid exponential increase in publications, with medical student led peer-reviewed publications (PRPs) increasing 1000% and pre-residency fellow (PRF) PRPs increasing by 4900%. Learner involvement on PRPs pre-IRI was 31%, increasing to 72% post-IRI implementation. CONCLUSIONS: We present the IRI's success increasing academic productivity despite utilizing only non-resident learners. Students underrepresented in medicine and those at non-tier 1 institutions receive unequal research and clinical opportunities, therefore, prioritizing and providing sufficient opportunities/mentorship is crucial in their success in matching into competitive specialties. Our IRI allows for early faculty/resident student mentorship and gives students more flexibility as it allows medical students at varying stages to participate in research with no set time frame.
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BACKGROUND: Anterior lumbar interbody fusion (ALIF) is a well-established surgical approach in the treatment of degenerative pathology, trauma, infection, and neoplasia of the spine. This study sought to assess the usefulness of frailty as a predictor of non-home discharge (NHD) for patients who undergo the procedure. METHODS: Patient cases were extracted from the American College of Surgeons's National Surgical Quality Improvement Program database from 2012 to 2020. Univariable and receiver operating characteristic curve analyses were used to compare the 5-item Modified Frailty Index (mFI-5) to the Revised Risk Analysis Index (RAI-rev) in relation to NHD. RESULTS: Simple linear regression demonstrated that increasing frailty was associated with an increased likelihood of NHD among 25,317 patients (mFI-5 odds ratio: 2.13, 3.23, 8.4; RAI-rev odds ratio: 3.22, 9.6, 23.6 [P<0.001 for all]). In each instance, a Cochran-Armitage trend test was significant (P<0.001), indicating a linear association of increasing odds. The RAI-rev resulted in a C-statistic of 0.722, compared to 0.628 for the mFI-5, and was shown to have superior discriminative ability with a DeLong Test (P<0.001). CONCLUSIONS: Frailty, as measured by mFI-5 and RAI-rev, was associated with an increased likelihood of NHD in patients who underwent ALIF. This finding supports recent literature on the promising utility of these indices, especially the RAI-rev, in preoperative decision-making across multiple facets of neurosurgery.
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Background: Postoperative complications after cranial or spine surgery are prevalent, and frailty can be a key contributing patient factor. Therefore, we evaluated frailty's impact on 30-day mortality. We compared the discrimination for risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for predicting 30-day mortality. Methods: Patients with major complications following neurosurgery procedures between 2012- 2020 in the ACS-NSQIP database were included. We employed receiver operating characteristic (ROC) curve and examined discrimination thresholds for RAI, mFI-5, and increasing patient age for 30-day mortality. Independent relationships were examined using multivariable analysis. Results: There were 19,096 patients included in the study and in the ROC analysis for 30-day mortality, RAI showed superior discriminant validity threshold C-statistic 0.655 (95% CI: 0.644-0.666), compared to mFI-5 C-statistic 0.570 (95% CI 0.559-0.581), and increasing patient age C-statistic 0.607 (95% CI 0.595-0.619). When the patient population was divided into subsets based on the procedures type (spinal, cranial or other), spine procedures had the highest discriminant validity threshold for RAI (Cstatistic 0.717). Furthermore, there was a frailty risk tier dose response relationship with 30-day mortalityy (p<0.001). Conclusion: When a major complication arises after neurosurgical procedures, frail patients have a higher likelihood of dying within 30 days than their non-frail counterparts. The RAI demonstrated a higher discriminant validity threshold than mFI-5 and increasing patient age, making it a more clinically relevant tool for identifying and stratifying patients by frailty risk tiers. These findings highlight the importance of initiatives geared toward optimizing frail patients, to mitigate long-term disability.
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OBJECTIVE: To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection. METHODS: SM surgery cases were queried from the American College of Surgeons - National Surgical Quality Improvement Program database (2011-2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, "mortality/hospice") were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 2,235 cases were stratified by RAI score: 0-20, 22.7%; 21-30, 11.9%; 31-40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697-0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001). CONCLUSION: Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.
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BACKGROUND: Acute traumatic spinal cord injury (tSCI) requires rapid surgical intervention to maximize neurological function. Older patients comprise an increasingly larger proportion of SCI patients annually, necessitating accurate preoperative risk stratification tools. This study utilized a frailty-based preoperative risk stratification score to predict adverse events following non-elective neurosurgical intervention for acute tSCI patients. METHODS: The National Inpatient Sample (NIS) was queried for acute tSCI patients aged ≥18 who underwent spine surgery in 2019-2020. The Risk Analysis Index (RAI) was implemented with crosstabulation, to analyze frailty scores with the following binary outcome measures: overall complications, non-home discharge (NHD), extended length of stay (eLOS) (>75th percentile), and mortality. Area Under the Receiver Operating Characteristic (AUROC) analysis assessed the discriminative threshold of RAI compared to the modified 5-item Frailty Index (mFI-5) for NHD and 30-day mortality. RESULTS: A total of 9995 SCI patients underwent non-elective spine surgery. There were 1525 perioperative complications (15.3%) and 510 (5.1%) mortalities. An increasing RAI score was significantly associated with increasing postoperative mortality rates: RAI 0-20 (1.5%, N.=45), RAI 21-30 (3.4%, N.=110), RAI 31-40 (6.8%, N.=115), and RAI>41 (11.8%, N.=240) (P<0.001). RAI demonstrated superior discrimination compared to the mFI-5 for mortality and NHD with a C-statistic >0.72. CONCLUSIONS: Increasing frailty, as measured by RAI, was a reliable predictor of non-home discharge and 30-day mortality for SCI patients who underwent non-elective spinal surgery and RAI demonstrated superior discrimination compared to the mFI-5 for NHD and mortality.
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Introduction The aim of this study was to evaluate the discriminative accuracy of the preoperative Risk Analysis Index (RAI) frailty score for prediction of mortality or transition to hospice within 30 days of brain tumor resection (BTR) in a large multicenter, international, prospective database. Methods Records of BTR patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program (2012-2020) database. The relationship between the RAI frailty scale and the primary end point (mortality or discharge to hospice within 30 days of surgery) was assessed using linear-by-linear proportional trend tests, logistic regression, and receiver operating characteristic (ROC) curve analysis (area under the curve as C-statistic). Results Patients with BTR ( N = 31,776) were stratified by RAI frailty tier: 16,800 robust (52.8%), 7,646 normal (24.1%), 6,593 frail (20.7%), and 737 severely frail (2.3%). The mortality/hospice rate was 2.5% ( n = 803) and was positively associated with increasing RAI tier: robust (0.9%), normal (3.3%), frail (4.6%), and severely frail (14.2%) ( p < 0.001). Isolated RAI was a robust discriminatory of primary end point in ROC curve analysis in the overall BTR cohort (C-statistic: 0.74; 95% confidence interval [CI]: 0.72-0.76) as well as the malignant (C-statistic: 0.74; 95% CI: 0. 67-0.80) and benign (C-statistic: 0.71; 95% CI: 0.70-0.73) tumor subsets (all p < 0.001). RAI score had statistically significantly better performance compared with the 5-factor modified frailty index and chronological age (both p < 0.0001). Conclusions RAI frailty score predicts 30-day mortality after BTR and may be translated to the bedside with a user-friendly calculator ( https://nsgyfrailtyoutcomeslab.shinyapps.io/braintumormortalityRAIcalc/ ). The findings hope to augment the informed consent and surgical decision-making process in this patient population and provide an example for future study designs.
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OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) predominantly occurs in older patients, and ventriculoperitoneal shunt (VPS) placement is the definitive surgical treatment. VPS surgery carries significant postoperative complication rates, which may tip the risk/benefit balance of this treatment option for frail, or higher-risk, patients. In this study, the authors investigated the use of frailty scoring for preoperative risk stratification for adverse event prediction in iNPH patients who underwent elective VPS placement. METHODS: The Nationwide Readmissions Database (NRD) was queried from 2018 to 2019 for iNPH patients aged ≥ 60 years who underwent VPS surgery. Risk Analysis Index (RAI) and modified 5-item Frailty Index (mFI-5) scores were calculated and RAI cross-tabulation was used to analyze trends in frailty scores by the following binary outcome measures: overall complications, nonhome discharge (NHD), extended length of stay (eLOS) (> 75th percentile), and mortality. Area under the receiver operating characteristic curve analysis was performed to assess the discriminatory accuracy of RAI and mFI-5 for primary outcomes. RESULTS: A total of 9319 iNPH patients underwent VPS surgery, and there were 685 readmissions (7.4%), 593 perioperative complications (6.4%), and 94 deaths (1.0%). Increasing RAI score was significantly associated with increasing rates of postoperative complications: RAI scores 11-15, 5.4% (n = 80); 16-20, 5.6% (n = 291); 21-25, 7.6% (n = 166); and ≥ 26, 11.6% (n = 56). The discriminatory accuracy of RAI was statistically superior (DeLong test, p < 0.05) to mFI-5 for the primary endpoints of mortality, NHD, and eLOS. All RAI C-statistics were > 0.60 for mortality within 30 days (C-statistic = 0.69, 95% CI 0.68-0.70). CONCLUSIONS: In a nationwide database analysis, increasing frailty, as measured by RAI, was associated with NHD, 30-day mortality, unplanned readmission, eLOS, and postoperative complications. Although the RAI outperformed the mFI-5, it is essential to account for the potentially reversible clinical issues related to the underlying disease process, as these factors may inflate frailty scores, assign undue risk, and diminish their utility. This knowledge may enhance provider understanding of the impact of frailty on postoperative outcomes for patients with iNPH, while highlighting the potential constraints associated with frailty assessment tools.
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Fragilidad , Hidrocéfalo Normotenso , Humanos , Anciano , Fragilidad/complicaciones , Fragilidad/cirugía , Derivación Ventriculoperitoneal/efectos adversos , Hidrocéfalo Normotenso/cirugía , Hidrocéfalo Normotenso/complicaciones , Medición de Riesgo , Factores de Riesgo , Complicaciones Posoperatorias/etiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: There is a rising prevalence of overweight and obese persons in the US, and there is a paucity of information about the relationship between frailty and body mass index. Therefore, we examined discrimination thresholds and independent relationships of the risk analysis index (RAI), modified frailty index-5 (mFI-5), and increasing patient age in predicting 30-day postoperative mortality. METHODS: This retrospective American College of Surgeons National Surgical Quality Improvement Program analysis compared all overweight or obese adult patients who underwent neurosurgery procedures between 2012 and 2020. We compared discrimination using receiver operating characteristic curve analysis for RAI, mFI-5, and increasing patient age. Furthermore, multivariable analyses, as well as subgroup analyses by procedure type i.e., spine, skull base, and other (vascular and functional) were performed, and reported as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We included 315,725/412,909 (76.5%) neurosurgery patients, with a median age of 59 years (interquartile range: 48-68), predominately White 76.7% and male 54.3%. Receiver operating characteristic analysis for 30-day postoperative mortality demonstrated a higher discriminatory threshold for RAI (C-statistic: 0.790, 95%CI: 0.782-0.800) compared to mFI-5 (C-statistic: 0.692, 95%CI: 0.620-0.638) and increasing patient age (C-statistic: 0.659, 95%CI: 0.650-0.668). Multivariable analyses showed a dose-dependent association and a larger magnitude of effect by RAI: frail patients OR: 11.82 (95%CI: 10.57-13.24), and very frail patients OR: 31.19 (95%CI: 24.87-39.12). A similar trend was observed in all subgroup analyses i.e., spine, skull base, and other (vascular and functional) procedures (P ≤ 0.001). CONCLUSIONS: Increasing frailty was associated with a higher rate of 30-day postoperative mortality, with a dose-dependent effect. Furthermore, the RAI had a higher threshold for discrimination and larger effect sizes than mFI-5 and increasing patient age. These findings support RAI's use in preoperative assessments, as it has the potential to improve postoperative outcomes through targeted interventions.
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Fragilidad , Neurocirugia , Adulto , Anciano , Humanos , Masculino , Persona de Mediana Edad , Fragilidad/complicaciones , Anciano Frágil , Estudios Retrospectivos , Índice de Masa Corporal , Sobrepeso/complicaciones , Medición de Riesgo/métodos , Obesidad/complicaciones , Complicaciones Posoperatorias/epidemiología , Factores de RiesgoRESUMEN
Importance: Frailty is associated with adverse outcomes after even minor physiologic stressors. The validated Risk Analysis Index (RAI) quantifies frailty; however, existing methods limit application to in-person interview (clinical RAI) and quality improvement datasets (administrative RAI). Objective: To expand the utility of the RAI utility to available International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) administrative data, using the National Inpatient Sample (NIS). Design, Setting, and Participants: RAI parameters were systematically adapted to ICD-10-CM codes (RAI-ICD) and were derived (NIS 2019) and validated (NIS 2020). The primary analysis included survey-weighed discharge data among adults undergoing major surgical procedures. Additional external validation occurred by including all operative and nonoperative hospitalizations in the NIS (2020) and in a multihospital health care system (UPMC, 2021-2022). Data analysis was conducted from January to May 2023. Exposures: RAI parameters and in-hospital mortality. Main Outcomes and Measures: The association of RAI parameters with in-hospital mortality was calculated and weighted using logistic regression, generating an integerized RAI-ICD score. After initial validation, thresholds defining categories of frailty were selected by a full complement of test statistics. Rates of elective admission, length of stay, hospital charges, and in-hospital mortality were compared across frailty categories. C statistics estimated model discrimination. Results: RAI-ICD parameters were weighted in the 9â¯548â¯206 patients who were hospitalized (mean [SE] age, 55.4 (0.1) years; 3â¯742â¯330 male [weighted percentage, 39.2%] and 5â¯804â¯431 female [weighted percentage, 60.8%]), modeling in-hospital mortality (2.1%; 95% CI, 2.1%-2.2%) with excellent derivation discrimination (C statistic, 0.810; 95% CI, 0.808-0.813). The 11 RAI-ICD parameters were adapted to 323 ICD-10-CM codes. The operative validation population of 8â¯113â¯950 patients (mean [SE] age, 54.4 (0.1) years; 3â¯148â¯273 male [weighted percentage, 38.8%] and 4â¯965â¯737 female [weighted percentage, 61.2%]; in-hospital mortality, 2.5% [95% CI, 2.4%-2.5%]) mirrored the derivation population. In validation, the weighted and integerized RAI-ICD yielded good to excellent discrimination in the NIS operative sample (C statistic, 0.784; 95% CI, 0.782-0.786), NIS operative and nonoperative sample (C statistic, 0.778; 95% CI, 0.777-0.779), and the UPMC operative and nonoperative sample (C statistic, 0.860; 95% CI, 0.857-0.862). Thresholds defining robust (RAI-ICD <27), normal (RAI-ICD, 27-35), frail (RAI-ICD, 36-45), and very frail (RAI-ICD >45) strata of frailty maximized precision (F1 = 0.33) and sensitivity and specificity (Matthews correlation coefficient = 0.26). Adverse outcomes increased with increasing frailty. Conclusion and Relevance: In this cohort study of hospitalized adults, the RAI-ICD was rigorously adapted, derived, and validated. These findings suggest that the RAI-ICD can extend the quantification of frailty to inpatient adult ICD-10-CM-coded patient care datasets.
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Fragilidad , Mortalidad Hospitalaria , Clasificación Internacional de Enfermedades , Humanos , Masculino , Femenino , Anciano , Fragilidad/diagnóstico , Medición de Riesgo/métodos , Persona de Mediana Edad , Anciano de 80 o más Años , Estados Unidos/epidemiología , Evaluación Geriátrica/métodos , Evaluación Geriátrica/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Anciano Frágil/estadística & datos numéricosRESUMEN
Objective: To compare the predictive abilities of two frailty indices on post-operative morbidity and mortality in patients undergoing pituitary adenoma resection. Methods: The National Surgical Quality Improvement Program (NSQIP) database was used to retrospectively collect data for patients undergoing pituitary adenoma resection between 2015-2019. To compare the predictive abilities of two of the most common frailty indices, the 5-point modified frailty index (mFI-5) and the risk analysis index (RAI), receiver operating curve analysis (ROC) and area under the curve (AUC)/Cstatistic were used. Results: In our cohort of 1,454 patients, the RAI demonstrated superior discriminative ability to the mFI-5 in predicting extended length of stay (C-statistic 0.59, 95% CI 0.56-0.62 vs. C-statistic 0.51, 95% CI: 0.48-0.54, p = 0.0002). The RAI only descriptively appeared superior to mFI-5 in determining mortality (C-statistic 0.89, 95% CI 0.74-0.99 vs. Cstatistic 0.63, 95% CI 0.61-0.66, p=0.11), and NHD (C-statistic 0.68, 95% CI 0.60-0.76 vs. C-statistic 0.60, 95% CI: 0.57-0.62, p=0.15). Conclusions: Pituitary adenomas account for one of the most common brain tumors in the general population, with resection being the preferred treatment for patients with most hormone producing tumors or those causing compressive symptoms. Although pituitary adenoma resection is generally safe, patients who experience post-operative complications frequently share similar pre-operative characteristics and comorbidities. Therefore, appropriate pre-operative risk stratification is imperative for adequate patient counseling and informed consent in these patients. Here we present the first known report showing the superior discriminatory ability of the RAI in predicting eLOS when compared to the mFI-5.
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Objective: In recent years, frailty has been reported to be an important predictive factor associated with worse outcomes in neurosurgical patients. The purpose of the present systematic review was to analyze the impact of frailty on outcomes of chronic subdural hematoma (cSDH) patients. Methods: We performed a systematic review of literature using the PubMed, Cochrane library, Wiley online library, and Web of Science databases following PRISMA guidelines of studies evaluating the effect of frailty on outcomes of cSDH published until January 31, 2023. Results: A comprehensive literature search of databases yielded a total of 471 studies. Six studies with 4085 patients were included in our final qualitative systematic review. We found that frailty was associated with inferior outcomes (including mortality, complications, recurrence, and discharge disposition) in cSDH patients. Despite varying frailty scales/indices used across studies, negative outcomes occurred more frequently in patients that were frail than those who were not. Conclusions: While the small number of available studies, and heterogenous methodology and reporting parameters precluded us from conducting a pooled analysis, the results of the present systematic review identify frailty as a robust predictor of worse outcomes in cSDH patients. Future studies with a larger sample size and consistent frailty scales/indices are warranted to strengthen the available evidence. The results of this work suggest a strong case for using frailty as a pre-operative risk stratification measure in cSDH patients.
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â¢Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.â¢Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.â¢The FDA approved Andexanet alfa to treat life-threatening bleeding.â¢Andexanet alfa relationship to outcomes requires further investigation.
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Objective: We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management. Background: Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation. Methods: A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability. Results: Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata. Conclusion: Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.