Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial.

BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Developing a National Trauma Research Action Plan: Results from the geriatric research gap Delphi survey.

BACKGROUND: Treating older trauma patients requires a focus on the confluence of age-related physiological changes and the impact of the injury itself. Therefore, the primary way to improve the care of geriatric trauma patients is through the development of universal, systematic multidisciplinary research. To achieve this, the Coalition for National Trauma Research has developed the National Trauma Research Action Plan that has generated a comprehensive research agenda spanning the continuum of geriatric trauma care from prehospital to rehabilitation. METHODS: Experts in geriatric trauma care and research were recruited to identify current gaps in clinical geriatric research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines ensuring heterogeneity and generalizability. On subsequent surveys, participants were asked to rank the priority of each research question on a nine-point Likert scale, categorized to represent low-, medium-, and high-priority items. The consensus was defined as more than 60% of panelists agreeing on the priority category. RESULTS: A total of 24 subject matter experts generated questions in 109 key topic areas. After editing for duplication, 514 questions were included in the priority ranking. By round 3, 362 questions (70%) reached 60% consensus. Of these, 161 (44%) were high, 198 (55%) medium, and 3 (1%) low priority. CONCLUSION: Among the questions prioritized as high priority, questions related to three types of injuries (i.e., rib fracture, traumatic brain injury, and lower extremity injury) occurred with the greatest frequency. Among the 25 highest priority questions, the key topics with the highest frequency were pain management, frailty, and anticoagulation-related interventions. The most common types of research proposed were interventional clinical trials and comparative effectiveness studies, outcome research, and health care systems research.

Prospective evaluation of preoperative cognitive impairment and postoperative morbidity in geriatric patients undergoing emergency general surgery.

BACKGROUND: Cognitive impairment (CI) is common in geriatric patients. We aimed to evaluate the prevalence and impact of CI on outcomes in geriatric patients undergoing emergency general surgery (EGS). METHODS: We performed a (2017-2018) prospective analysis of patients (age ≥65y) who underwent EGS. Cognition was assessed using the Montreal Cognitive Assessment (MoCA). Patients were stratified into: CI (MoCA score<26) and no-CI (MoCA≥26). Outcomes were the prevalence of CI, in-hospital complications, discharged to rehab/skilled nursing facility (SNF), and mortality. RESULTS: A total of 142 patients were enrolled. Overall prevalence of CI was 20%. Patients with CI had higher rates of complications (OR 1.6 [1.4-1.9]; p = 0.01), and discharge to rehab/SNF (OR 2.2 [2.0-2.5]; p = 0.03). There was no difference in mortality (OR 1.1 [0.6-1.8]; p = 0.24) between the 2 groups. CONCLUSION: One in five geriatric EGS patients has CI. It is associated with higher complications and adverse discharge. Cognitive assessment should be included in preoperative risk stratification.

Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery.

BACKGROUND: The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients. STUDY DESIGN: We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery. RESULTS: A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01). CONCLUSIONS: The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events.

Prospective evaluation and comparison of the predictive ability of different frailty scores to predict outcomes in geriatric trauma patients.

BACKGROUND: Different frailty scores have been proposed to measure frailty. No study has compared their predictive ability to predict outcomes in trauma patients. The aim of our study was to compare the predictive ability of different frailty scores to predict complications, mortality, discharge disposition, and 30-day readmission in trauma patients. METHODS: We performed a 2-year (2016-2017) prospective cohort analysis of all geriatric (age, >65 years) trauma patients. We calculated the following frailty scores on each patient; the Trauma-Specific Frailty Index (TSFI), the Modified Frailty Index (mFI) derived from the Canada Study of Health and Aging, the Rockwood Frailty Score (RFS), and the International Association of Nutrition and Aging 5-item a frailty scale (FS). Predictive models, using both unadjusted and adjusted logistic regressions, were created for each outcome. The unadjusted c-statistic was used to compare the predictive ability of each model. RESULTS: A total of 341 patients were enrolled. Mean age was 76 ± 9 years, median Injury Severity Score was 13 [9-18], and median Glasgow Coma Scale score was 15 [12-15]. The unadjusted models indicated that both the TSFI and the RFS had comparable predictive value, as indicated by their unadjusted c-statistics, for mortality, in-hospital complications, skilled nursing facility disposition and 30-day readmission. Both TSFI and RFS models had unadjusted c-statistics indicating a relatively strong predictive ability for all outcomes. The unadjusted mFI and FS models did not have a strong predictive ability for predicting mortality and in-hospital complications. They also had a lower predictive ability for skilled nursing facility disposition and 30-day readmissions. CONCLUSION: There are significant differences in the predictive ability of the four commonly used frailty scores. The TSFI and the RFS are better predictors of outcomes compared with the mFI and the FS. The TSFI is easy to calculate and might be used as a universal frailty score in geriatric trauma patients. LEVEL OF EVIDENCE: Prognostic, level III.

Prospective evaluation of health-related quality of life in geriatric trauma patients.

BACKGROUND: Frailty is an established predictor of adverse outcomes in geriatric patients. Health-related quality of life (HRQoL) is an important outcome measure among trauma patients. This prospective observational study examined the impact of frailty on health-related quality of life in geriatric trauma patients. METHODS: We prospectively enrolled geriatric (age ≥65 years) trauma patients. We calculated the frailty index (FI) within 24 hours of admission using the trauma-specific frailty index. Patients were stratified into frail (frailty index ≥0.27) and nonfrail (frailty index <0.27). Health-related quality of life was calculated at discharge and at 30 days (day) after discharge using the RAND Short Form-36 (SF-36). Outcome measures were health-related quality of life at discharge, 30-days postdischarge, and delta health-related quality of life. Regression analysis was performed to control for demographic, vital signs, and injury parameters. RESULTS: We enrolled 296 patients. The mean age was 75.1 ± 9.8 years, 59% were male, and 81% were white. Frail patients accounted for 34%, and they had a lower health-related quality of life at discharge (366 vs 548, P < .01) and at 30-day postdischarge (393 vs 744, P < .01). Nonfrail patients scored higher in 6 out of 8 domains of health-related quality of life. Nonfrail patients had improved delta health-related quality of life (P < .01), unlike frail patients (P = .11). A linear regression model revealed an inverse relationship between frailty and improvement in health-related quality of life over 30-day postdischarge (ß = -0.689, [confidence interval, -0.963 to -0.329] P = .01). This association remained statistically significant after controlling for potential confounding covariates, such as age, sex, race, and injury severity. CONCLUSION: Compared with nonfrail geriatric trauma patients, those who were frail had poor health-related quality of life at discharge and at 30-day postdischarge. Frailty negatively affects the recovery of health-related quality of life after trauma. The use of frailty indices may help identify and develop targeted interventions to improve health-related quality of life among geriatric trauma patients.

Frailty as a prognostic factor for the critically ill older adult trauma patients.

BACKGROUND: Frailty is highly prevalent in the elderly and confers high risk for adverse outcomes. We aimed to assess the impact of frailty on critically ill older adult trauma patients. METHODS: We analyzed the ACS-TQIP(2010-2014) including all critically-ill trauma patients ≥65y. The modified frailty index (mFI) was calculated. Following stratified into frail and non-frail, propensity score matching was performed. Our primary outcome measure was in-hospital complications. Secondary outcome measures included mortality and discharge disposition. RESULTS: We identified 88,629 patients, of which 34,854 patients (frail: 17,427, non-frail: 17,427) were matched. Overall 14% died. Frail patients had higher rates of complications (34% vs. 18%, p < 0.001), mortality (18.1% vs. 9.7%, p < 0.001), and were more likely to be discharged to rehab/SNF (58.7% vs. 21.2% p < 0.001) compared to non-frail patients. CONCLUSION: critically-ill frail patients are more likely to have higher morbidity and mortality. Frailty can be used as an objective measure to identify high-risk patients.

Failure to Rescue After Emergency General Surgery in Geriatric Patients: Does Frailty Matter?

BACKGROUND: Failure to rescue (FTR) is considered as an index of quality of care provided by a hospital. However, the role of frailty in FTR remains unclear. We hypothesized that the FTR rate is higher for frail geriatric emergency general surgery (EGS) patients than nonfrail geriatric EGS patients. METHODS: We performed a 3-y (2015-2017) prospective cohort study of all geriatric patients (age ≥ 65 y) requiring EGS. Frailty was calculated by using the EGS-specific Frailty Index (EGSFI) within 24 h of admission. Patients were divided into two groups: frail (FI ≥ 0.325) and nonfrail (FI < 0.325). We defined FTR as death from a major complication. Regression analysis was performed to control for demographics, type of operative intervention, admission vitals, and admission laboratory values. RESULTS: Three hundred twenty-six geriatric EGS patients were included, of which 38.9% were frail. Frail patients were more likely to be white (P < 0.01) and, on admission, had a higher American Association of Anesthesiologist class (P = 0.03) and lower serum albumin (P < 0.01). However, there was no difference between the groups regarding age (P = 0.54), gender (P = 0.56), admission vitals, and WBC count (P = 0.35). Overall, 26.7% (n = 85) of patients developed in-hospital complications; and mortality occurred in 30% (n = 26) of those patients (i.e., the FTR group). Frail patients had higher rates of FTR (14% vs. 4%, P < 0.001) than nonfrail patients. On regression analysis, after controlling for confounders, frail status was an independent predictor of FTR (OR: 3.4 [2.3-4.6]) in geriatric EGS patients. CONCLUSIONS: Our study demonstrates that in geriatric EGS patients, a frail status independently contributes to FTR and increases the odds of FTR threefold compared with nonfrail status. Thus, it should be included in quality metrics for geriatric EGS patients.

Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan.

BACKGROUND: In 2002 Afghanistan's Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. METHODS: The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis. RESULTS: While some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other. CONCLUSION: Three sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan's example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries.