American College of Surgeons Frailty Index: A Comprehensive Overview
Introduction
Frailty is a state of reduced physiological reserve that increases vulnerability to stressors. In the context of surgery, frailty significantly impacts patient outcomes. A frailty index utilizes multiple variables to predict adverse surgical outcomes, prompting the need for accurate and reliable frailty assessment methods. The American College of Surgeons (ACS) has been actively involved in studying and implementing frailty assessments to improve surgical care for older adults.
Defining and Measuring Frailty
Frailty describes a state of reduced physiologic reserve. Several tools and indices exist to quantify frailty, each with its strengths and limitations. These tools often incorporate various factors, including physical function, comorbidities, and cognitive status.
One such tool is the frailty index (FI), which uses many variables to predict poor surgical outcomes. The modified frailty index (mFI) is another commonly used tool, particularly within the National Surgical Quality Improvement Program (NSQIP) database. The mFI-11, an 11-factor index based on NSQIP data, has been shown to adequately reflect frailty and predict mortality and morbidity. However, changes in NSQIP data collection have led to the development of a simplified 5-factor index (mFI-5). Studies have demonstrated that the mFI-5 correlates strongly with the mFI-11 and remains a strong predictor of mortality and postoperative complications.
More recently, the Modified 4-Factor Functional Frailty Index (mFF-4) has emerged, incorporating variables that embody the frailty phenotype: history of falls, dementia, low body mass index, and non-independent functional status. The mFF-4 has been shown to accurately predict 30-day mortality, postoperative complications, and geriatric outcomes.
Surgeon Assessment vs. Frailty Index
A study was conducted to determine the agreement between a surgeon’s clinical determination of frailty and a validated frailty index score. Patients aged 60 or older seeking a general surgery consultation were recruited, excluding those with recent traumatic brain injury or dementia. Following consent, patients completed a validated frailty survey, with a score of 16 or greater indicating frailty. Surgeons independently assessed patient frailty based on clinical history and physical examination.
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The study involved 122 patients, with surgeons deeming 32 patients frail and the frailty index identifying 39 as frail (p=0.69). The average frailty score was 16.1 (±7.91) based on surgeon assessment, compared to 21.9 (±4.15) as determined by the frailty index (d=5.81; p=0.0001). Cohen’s Kappa statistic revealed a fair agreement of 71.3% (k=0.307, 95% CI = 0.127-0.488; p<0.05) between the surgeon’s determination and the frailty index. The sensitivity and specificity were 46.2% and 83.1% for all patients, respectively. Among non-cancer patients (n=92), the sensitivity increased to 77.8%, while specificity remained the same. This study highlights that there is fair agreement between the surgeon’s determination and the frailty index.
The Surgical Pause: A Proactive Approach
Recognizing the unique challenges posed by frail patients, surgeon and researcher Daniel E. Hall developed the Surgical Pause, a screening tool designed to identify at-risk patients. This tool consists of a 12-item Risk Analysis Index (RAI). Patients identified as high-risk undergo further evaluation using an interdisciplinary approach that may include prehabilitation and a structured conversation to clarify the patient’s goals and expectations prior to surgical decision-making.
Prehabilitation may involve preoperative exercise to improve physical condition and respiratory function, as well as nutritional supplementation. Goal clarification extends beyond informed consent, framing the surgical decision within the context of the patient’s life and overall goals. Surgeons and their staff guide patients through this discussion, using easily understandable language to describe the potential outcomes of surgery versus nonoperative management.
Implementing the Surgical Pause requires dedicating 5-10 hours a week for the first three months to establish the program. Afterward, only a few hours a week are needed to review frail cases and generate periodic reports of process and outcomes measures. The VHA received a 2023 John M. Eisenberg Patient Safety and Quality Award from The Joint Commission and National Quality Forum for the development of this tool, which screens patients quickly, simply, and effectively.
Risk Analysis Index (RAI) and Treatment Pathways
The Risk Analysis Index (RAI) plays a crucial role in triaging patients and guiding treatment decisions. A study by Baldacchino MM, McQuestion CC, Giuca MS, et al., published in Annals of Surgery, demonstrated the utility of the RAI in assigning patients to one of four pathways: proceed as planned (G1), proceed after medical optimization (G2), modify to less invasive surgery or anesthesia (G3), or nonsurgical management (G4).
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The mean RAI increased with treatment conservatism: 36.4 in G1, 37.4 in G2, 41.4 in G3, and 44.2 in G4. Notably, 30-day mortality ranged from 6.6% in G1 to 19.8% in G4, and 1-year mortality was similar for G1 and G2 at approximately 33% to 35%, but it was higher in G3 and G4 at approximately 51% to 56%. Average survival favored G1 and G2, approximately 35 months, versus 20 and 18 months in G3 and G4, respectively. These findings suggest that routine frailty screening with the RAI is a strong triage signal for MDSPC referral and pathway selection, ultimately leading to more appropriate and personalized treatment strategies.
The Importance of Frailty Assessment in Surgical Decision-Making
The US population is aging, and most seniors would like to be mobile and have good cardiovascular, neurologic, and orthopaedic health in their retirement years. Recognizing that procedures performed on senior, frail patients are very different from similar procedures performed on healthy young patients is crucial. A study of 432,828 unique patients found that 8.5% of patients identified as frail had a mortality rate of 1.55% at 30 days after undergoing what is considered very low-stress surgeries. This 30-day rate increased to 22.26% after high-stress surgeries were performed on very frail patients, who comprised 2.1% of the sample. These mortality rates clearly show the need to evaluate the frailty of patients prior to surgery. High-risk frail patients require a different approach in order to have the best possible outcomes.
Broader Applications of ACS Initiatives
Beyond frailty assessment, the American College of Surgeons is involved in initiatives to improve surgical outcomes and patient care. One such area is the appropriate use of antibiotic decontamination in colorectal resections. A study found that implementing antibiotic decontamination and mechanical bowel preparation in left-sided colorectal resections across an entire healthcare region was associated with reduced overall complication severity, without impacting rates of anastomotic leakage or surgical site infection, according to multivariate logistic regression analysis.
Another area of focus is addressing treatment mismatches in specific cancers. An analysis of the National Cancer Database revealed a treatment mismatch for patients with clinical T2N0M0 esophageal squamous cell carcinoma: low-risk tumors are often undertreated with upfront esophagectomy, while high-risk tumors are frequently overtreated with chemoradiation therapy alone. These findings highlight the importance of individualized treatment approaches based on patient-specific risk factors and tumor characteristics.
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