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Table 1 Study demographics grouped by type of surgery

From: Frailty and post-operative outcomes in older surgical patients: a systematic review

Author Sample size
Country of origin
Mean or median age
% female
Study design
Type of surgery Frailty measure Adverse outcome predicted by frailty Association between frailty and adverse outcomes
Cardiac
 Afilalo, J et al. [17]a 152
USA,
Canada
Mean age 75.9
34 % female
Prospective cohort study
Cardiac surgery
(Elective)
Fried criteria (or Cardiovascular Health Study frailty scale)
Modified CHS frailty scale
Fried + cognitive impairment + depressed mood
4-item MSSA frailty scale
gait speed, handgrip strength, inactivity, cognitive impairment
Gait speed
Composite end point of post-operative mortality or major morbidity Fried criteria, non-sig
Modified CHS frailty scale, non-sig
4 item MSSA frailty scale, non-sig
Gait speed, OR 2.63 (p < 0.05)
 Green, P et al. [39]a 244
USA
Median age, %female
- frail 87.1,53 %
- non-frail 85.4,45 %
Post-hoc analysis of PARTNER trial
Transcatheter Aortic Valve Replacement (TAVR)
(Elective)
Fried criteria condensed into 4 domains
gait speed, grip strength, serum albumin, Katz index of ADL
Frail ≥6/12
1) Adverse clinical events at 30 days
2) 1 year mortality
3) Poor outcome (composite mortality & QoL assessed by KCCQ-OS) a) 6 months
b) 1 year
Adjusted for covariates
1) non-sig
2) OR 2.5 (p = 0.0002)
3)
a) OR 2.21 (p = 0.03)
b) OR 2.4 (p = 0.02)
 Green, P. et al. [18]b 159
USA
Mean age 86
50 % female
Prospective cohort study
Transcatheter aortic valve replacement, (TAVR)
(Elective)
Fried criteria condensed into 4 domains
gait speed, grip strength, serum albumin, Katz index of ADL
Frail >5/12
1) 1 year mortality
2) LOS
3) Procedural outcomes (any of major bleeding event, major vascular complications, stroke, acute kidney injury, 30 day mortality)
Adjusted for covariates
1) OR 3.5 (p = 0.006)
2) 9 vs 6 days (p = 0.004)
3) OR 2.2 (p = 0.04) for major bleeding but not other adverse outcomes
 Kamga, M et al. [19]b 30
Belgium
Mean age 86
47 % female
Prospective cohort study
TAVI
(Elective)
Score Hospitalier d'Evaluation du Risque de Perte d'Autonomie (SHERPA-risk of functional decline) score
MMSE, age, perceived poor health, fall in the last year, number of iADL independently performed before admission
Identification of Seniors at Risk (ISAR) score
>3 medications, self reported memory problems, sensory problems, hospital admission within the last 6 months, increased need for help at home
1) 1 year mortality
2) Major cardiac and cerebral adverse events (MACCE)
Adjusted for covariates
1) SHERPA HR2.74 for every 1 point increase in score
(p = 0.004)
ISAR non-sig
2) SHERPA non-sig
ISAR non-sig
 Schoenenberger, A.W. et al. [20]a 119
Switzerland
Mean age 83.4
55.5 % female
Prospective cohort study
TAVI
(Elective)
Mini Mental State Exam, Mini Nutritional Assessment, TUG, BADL, IADL, pre-clinical mobility disability
Frail ≥3
1) Functional decline (BADL ↓ ≥1 point)
2) Functional decline or death among all participants at 6 months
Univariate
1) OR 3.31 (p = 0.02)
2) OR 4.46 (p = 0.001)
 Stortecky, S. et al. [21]a 100
Switzerland
Mean age 83.7
60 % female
Prospective cohort study
TAVI
(Elective)
Mini Mental State Exam, Mini Nutritional Assessment, TUG, BADL, IADL, pre-clinical mobility disability
Frail ≥3
1) 30 day MACCE
2) 30 day mortality
3) 1 year MACCE
4) 1-year mortality
Univariate analysis
1) OR 4.78 (p = 0.05)
2) OR 8.33 (p = 0.03)
3) OR 4.89 (p = 0.003)
4) OR 3.68 (p = 0.02)
 Sundermann S, et al. [22]b 400
Germany
Mean age 80.3% female not reported
Prospective cohort study
Cardiac surgery
(Elective)
Comprehensive Assessment of Frailty
Fried minus unintentional weight loss, plus balance assessment, albumin, creatinine, brain natriuretic peptide, FEV1 and Clinical Frailty Scale
moderately frail = 11–25 points
severely frail = 26–35 points
30 day mortality Severely frail vs non frail
21.7 % vs 3.6 %
AUC = 0.71 on logistic regression
 Sundermann S, et al. [23]b 213
Germany
Mean age 80.1 % female not reported
Prospective cohort study
Cardiac surgery (Elective) CAF
FORECAST (Frailty predicts death One year after Elective Cardiac Surgery Tests)
1) 1 year mortality
2) Requirement for resuscitation
3) ICU stay
4) MACCE
1) 1 year mortality
Adjusted for EuroSCORE
1) OR 1.097 (p = 0.001)
AUC 0.70
Frail vs non frail
2) 16 % vs 2 % (p < 0.05)
3) non-sig
4) non-sig
1) FORECAST AUC 0.76
 Sundermann S, et al. [24]b 450
Germany
Mean age 79
50 % female
Prospective cohort study
Cardiac surgery (Elective) CAF
FORECAST
chair rise test, subjective weakness on questionnaire, stair climbing, Clinical Frail Scale and serum creatinine.
1 year mortality Adjusted for age
CAF OR 1.091 (p < 0.001)
FORECAST OR 1.265 (p < 0.001)
Oncologic
 Kristjansson S.R. et al. [25]a 178
Norway
Mean age 79.63
57 % female
Prospective cohort study
Colorectal cancer surgery
(Elective)
Balducci Frailty Criteria from CGA
Cumulative Illness Rating Scale (CIRS), pADL, iADL, polypharmacy, MNA, MMSE, and GDS
30 day post-operative complications (Clavian-Dindo grading) Adjusted for covariates
OR 3.13 (95 % CI 1.65–5.92)
 Kristjansson S.R. et al. [26]a 176
Norway
Mean age 80
57 % female
Prospective longitudinal study
Cancer surgery
(Elective)
Balducci Frailty Criteria from CGA
Modified Fried criteria
30 day mortality Adjusted for cancer stage and age
Balducci OR 3.39 (p < 0.001)
Modified Fried OR 2.67 (p = 0.029)
 Neuman, H.B. et al. [37]a 12,979
USA
Mean age 84.4
61.4 % female
Retrospective analysis of Surveillance, Epidemiology and End Results(SEER)-Medicare database
Colectomy for stage I to III colon cancer
(Elective)
11 item frailty measure defined by the John Hopkins Adjusted Clinical Group case-mix system
Difficulty walking, weight loss, frequent falls, malnutrition, impaired vision, decubitus ulcer, incontinence (plus 4 additional unnamed conditions)
Frail ≥1/11
1) 90 day survival
2) 1-year survival
Adjusted for covariates
1) OR 10.4 (p < 0.001)
2) OR 8.4 (p < 0.001)
 Ommundsen, N. et al. [27]a 178
Norway
Mean age 80
57 % female
Prospective cohort study
Colorectal cancer surgery
(Elective)
Balducci Frailty Criteria from CGA 5 year mortality Multivariate adjusted for TNM stage and sex
OR 3.6 (p < 0.001)
 Ronning, B. et al. [28]b 84
Norway
Median age 82
59 % female
Prospective cohort study
Colorectal cancer surgery
(Elective)
Balducci Frailty Criteria from CGA Post-operative functional status
1) Barthel Index ↓
2) NEADL ↓
3) TUG ↑
4) Grip strength ↓
Logistic regression (95 % CI)
1) non-sig
2) non-sig
3) non-sig
4) non-sig
 Tan, K-Y et al. [29]b 83
Singapore and Japan
Mean age 81.5 % female not reported
Prospective cohort study
Colorectal cancer
(Elective)
Fried criteria Postop complications (Clavien-Dindo ≥ II) Bivariate analysis
OR 4.08 (p = 0.006)
General/abdominal
 Hewitt, J. et al. [30]a 325
UK
Mean age 77.6
57 % female
Prospective cohort study
General surgical patients
(Acute)
- only 31 % underwent surgery
Clinical Frailty Scale
7 frailty levels based on visual observation combined with an abbreviated review of medical records
Frail is ≥5
1) 30 day mortality
2) 90 day mortality
3) LOS
4) 30 day hospital readmission
Adjusted for age and polypharmacy, frail vs non frail
1) non-sig
2) non-sig
3) 19 vs 7 days (p = 0.02)
4) non-sig
 Kenig, J et al. [31]a 184
Poland
Mean age 76.9
53 % female
Prospective cohort study
Abdominal surgery
(Acute)
Vulnerable Elder Survey (VES)
age, self-rated health, limitation in physical function and functional disabilities
Triage Risk Screening Tool (TRST)
cognitive impairment, difficulty walking/transferring/recent falls, ≥5 medications, ED use in previous 30 days or hospitalization in previous 90 days, lives alone and/or no available caregiver, geriatric syndrome
G8
7 items from the Mini Nutritional Assessment (MNA) questionnaire and age
Groningen Frailty Indicator (GFI)
ADLs, sensory impairment, nutrition, polypharmacy, cognitive impairment, psychosocial wellbeing and subjective physical fitness
Rockwood’s brief clinical instrument to classify frailty (4 frailty levels)
Balducci Frailty Criteria
1) 30 day post-operative complications (Clavian-Dindo grading)
2) 30 day mortality
Adjusted for covariates
1) VES: OR 2.4 (p < 0.05)
TRST: non-sig
G8: OR 1.5 (p < 0.05)
GFI: OR 1.5 (p < 0.05)
Rockwood: non-sig
Balducci: OR 1.7 (p < 0.05)
2) VES: OR 2.4 (p < 0.05)
TRST: non-sig
G8: OR 1.8 (p < 0.05)
GFI: OR 1.4 (p < 0.05)
Rockwood: non-sig
Balducci: OR 1.4 (p < 0.05)
 Kim, S et al. [33]a 275
Korea
Mean age,% female
- survivors 75.2, 46 %
- deceased 77.6, 32 %
Prospective cohort study
Intermediate or high risk general surgery
(Elective)
Multidimensional Frailty Score (MFS)
Malignant disease, Charleston comorbidity Index, Albumin, ADLs, IADLs, dementia, risk of delirium, malnutrition, mid-arm circumference
Low risk ≤5
High risk >5
1) 1 year mortality
2) Discharge to residential care
3) Postoperative complications
4) LOS (median)
Adjusted for covariates, for every 1 point increase in MFS
1) OR 2.05 (p < 0.001)
2) OR 1.42 (p = 0.01)
3) non-sig
4) 14 vs 9 days for high vs low risk group (p < 0.001)
Vascular
 Ambler, G.K. et al. [32]b 410
UK
Median age 77 % female not reported
Prospective cohort study
Vascular surgery (Elective and Acute) Addenbrooke’s Vascular Frailty Score (AVFS; 6 items, score 0–6)
Not independently mobile on admission, depression, polypharmacy on admission (>8 medications), anaemia, Waterlow score >13 on admission, emergency admission
1) 1 year mortality
2) Readmission-free survival
3) Discharge to residential care
3) Prolonged LOS
Univariate; most vs least frail
1) 58 % vs 0 %, AUC 0.83
2) 0 % vs 68 % (p < 0001), AUC 0.71
3) AUC 0.78
4) AUC 0.74
 Partridge, J.S.L. et al. [34]a 125
UK
Mean age 76.3
31 % female
Prospective observational study
Vascular surgery
(Elective and Acute)
Edmonton Frail Scale (EFS)
cognitive impairment, dependence in iADL, recent burden of illnesses, self-perceived health, depression, weight loss, medication issues, incontinence, inadequate social support and mobility difficulties.
Frail is >7/18
1) Composite measure post-operative complications
2) Composite measure adverse functional outcomes
3) LOS ≥12 days
Multivariate, adjusted for significant baseline associations and age
1) non-sig
2) non-sig
3) non-sig
Hip fracture
 Kistler, E et al. [35]a 35
USA
Mean age 86
83 % female
Prospective cohort study
Hip fracture surgery
(Acute)
Modified Fried Criteria 1) Post-operative complications
2) Delirium
3) LOS
4) Time to surgery
Frail vs Non-frail
1) non-sig
2) non-sig
3) 7.3 vs 4.1 (p = 0.038)
4) non-sig
 Krishnan, M et al. [36]a 178
UK
Mean age 81
73.5 % female
Prospective cohort study
Hip fracture surgery
(Acute)
FI (51 items) 1) 30-day mortality
2) Inpatient mortality
3) LOS-failure to return home by 30 days
Frail vs Non-frail
1) 17.2 % vs 0 % (p < 0.001)
2) 28.1 % vs 0 % (p < 0.001)
3) AUC 0.82
 Patel K.V. et al. [38]a 218
USA
Mean age 81.2 % female not reported
Retrospective chart review
Hip fracture
(Acute)
Modified FI (19 items) 1 year mortality
2-year mortality
OR 4.97 (p < 0.001)
OR 4.01 (p < 0.001)
  1. aindicates quartile 1 in the quality assessment
  2. bindicates quartile 2 in the quality assessment
  3. LOS length of stay, MACCE major cardiac & cerebral adverse events, non-sig no statistically significant association, AUC area under the ROC curve for prediction of adverse outcomes