A Department of Veterans Affairs study has shown that frail surgery patients may be at higher risk than previously thought. Mortality rates were high for frail patients even after surgeries normally considered low-risk. This led the researchers to conclude that "there are no 'low-risk' procedures among frail patients."
The findings appear in the Nov. 13, 2019, issue of JAMA Surgery.
Dr. Myrick C. Shinall, Jr. of the Vanderbilt University Medical Center, first author on the paper, explains that the findings change the view of which surgeries are considered dangerous. "We certainly found it surprising that surgeries usually considered low-stress and low-risk had such high risk of mortality for frail patients," he said in a phone interview. "We think other surgeons will also be surprised by the results."
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Frailty refers to overall physical weakness. It is common in older adults. Frail patients have lowered resilience, energy, and ability to cope with stress. They show physical signs such as weakness and slowed activity.
As Shinall explains, the root cause of frailty is not completely known. Age is certainly a part of it, but not all people of a certain age become frail. Other co-occurring health problems, such as cardiovascular disease, play a part in patients becoming frail. Physical fitness also seems to protect against frailty to some extent.
While frailty is a well-known surgery concern, most research on frail patients has focused on high-risk surgeries. A surgery is usually considered high-risk when the post-surgery mortality rate is above 1%.
To test frailty's impact on surgeries generally considered less risky, the researchers looked at data on more than 400,000 veterans who had non-cardiac surgeries within the VA health care system. Out of this group, 8.5% were considered frail and 2.1% were very frail, based on a measure called the Risk Analysis Index (RAI).
Patients were grouped based on what type of surgery they had. Low-risk surgeries included hernia surgery, appendectomy, and cyst removal. Surgeries such as amputation; arterial plaque removal; and knee, shoulder, or hip replacement were considered moderate-risk. High-risk procedures were mostly open surgeries on the aorta, lungs, liver or pancreas.
Mortality rates for frail and very frail patients were "alarmingly high" across all levels of surgery, compared to stronger patients. Thirty days after a low-risk surgery, 1.6% of frail patients and 10.3% of very frail patients had died. Non-frail patients had a 0.22% mortality rate after low-risk surgery.