preoperative frailty risk analysis index to stratify ...• frailty is a syndrome with decreased...
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Preoperative Frailty Risk Analysis
Index to Stratify Patients Undergoing
Carotid Endarterectomy
Melin, Alyson A.1,2; Schmid, Kendra K.2; Lynch,
Thomas G.1; Kappes, Steven3; Pipinos, Iraklis I.1,2;
Longo, G. Matthew 1,2; Gupta, Prateek K.4;
Johanning, Jason M.1,2
1. NWI VA Medical Center, Omaha, NE, United States.
2. University of Nebraska Medical Center, Omaha, NE, United States.
3. Aurora Healthcare System, Milwaukee , WI, United States.
4. University of Wisconsin, Madison, WI, United States.
Introduction
• No disclosures
Introduction
• Carotid endarterectomy is under increased
scrutiny
• The value of carotid endarterectomy is
dependent on outcomes
• How can we improve outcomes in carotid
endarterectomy?
– Technical
– Patient Selection
Introduction
• How do we best select patients to undergo
carotid endarterectomy?
• Frailty is a syndrome with decreased
physiologic reserves arising from cumulative
comorbid conditions. 1, 2
1. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin
Geriatr Med. 2011;27(1):17-26
2. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and
comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):255-263.
1. Makary M, Sergev D, Pronovost P, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. J Am Coll Surg. 2010:
210 (6)
RISK ANALYSIS INDEX (RAI)
1. Age ____ Score with Cancer _____ (13-20)
Score without Cancer _____ (2-9)
2. Sex Female = 0/ Male = 5 _____ (5)
1. Renal Insufficiency No = 0/ Yes = 6 _____ (6)
2. Congestive Heart Failure No = 0/ Yes = 4 _____ (4)
3. Shortness of Breath at Rest No = 0/ Yes = 8 _____ (8)
4. Weight Loss (>10 lbs) in last 3 Months No = 0/ Yes = 5 _____ (5)
5. Poor Appetite No = 0/ Yes = 4 _____ (4)
6. Residence Other than Independent Living No = 0/ Yes = 8 _____ (8)
7. Cognitive Decline in last 3 Months No / Yes
1. Activities of Daily Living With Cognitive Decline _____(-2-21)
Without Cognitive Decline _____ (0-16)
TOTAL SCORE _____ (0-85)
75
4
5
6
0
0 0
0
8
2
25
1. Johnson M, Bailey T, Schmid K, et al. A frailty index identifies patients at high risk of mortality after tracheostomy. Otolaryngol Head Neck Surg. 2014; 150
(4): 568
2. Dwyer J, Reynoso J, Seevers G, et al. Assessing preoperative frailty utilizing validated geriatric mortality calculators and their association with
postoperative hip fracture mortality risk. Geriatr Orthop Surg Rehabil. 2014; Submission accepted
3. Ernst K, Lynch TG, Lavaden P, Seevers G, Schmid KK,Johanning JM, . Surgical palliative care consultations over time in relation to system wide frailty
screening. JAMA Surg. 2014; Submission accepted.
Study Design
• All patients in NSQIP database who underwent
CEA from 2005 – 2011 (n = 44,832)
• A quality and frailty team matched variables
from RAI to preoperative NSQIP parameters
• Primary outcome measures: Stroke, MI, Death,
Length of Stay
RAI Score Breakdown
17898
23233
1748 1290 417 156 58 25 5 2
0
5000
10000
15000
20000
25000
All Patients
7353
8137
908 858
243 126 45 20 4 2 0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Symptomatic Patients
10545
15096
840 432 174 30 13 5 1 0 0
2000
4000
6000
8000
10000
12000
14000
16000
Asymptomatic Patients
92%
88% 94%
All Patients
0%
10%
20%
30%
40%
50%
60%
Stroke (p = 0.0001)
Death (p < 0.0001)
MI (p = 0.0002)
* p = Cochran-Armitage Trend Test
Symptomatic Patients
0%
10%
20%
30%
40%
50%
60%
Stroke (p = 0.009)
Death (p <0.0001)
MI (0.002)
* p = Cochran-Armitage Trend Test
Asymptomatic Patients
0%
5%
10%
15%
20%
25%
Stroke (p = 0.22)
Death (p < 0.0001)
MI (p = 0.04)
* p = Cochran-Armitage Trend Test
Length of Stay
0
2
4
6
8
10
12
14
16
18
All Patients
Symptomatic Patients
Asymptomatic Patients
RISK ANALYSIS INDEX (RAI)
1. Age ____ Score with Cancer _____ (13-20)
Score without Cancer _____ (2-9)
2. Sex Female = 0/ Male = 5 _____ (5)
1. Renal Insufficiency No = 0/ Yes = 6 _____ (6)
2. Congestive Heart Failure No = 0/ Yes = 4 _____ (4)
3. Shortness of Breath at Rest No = 0/ Yes = 8 _____ (8)
4. Weight Loss (>10 lbs) in last 3 Months No = 0/ Yes = 5 _____ (5)
5. Poor Appetite No = 0/ Yes = 4 _____ (4)
6. Residence Other than Independent Living No = 0/ Yes = 8 _____ (8)
7. Cognitive Decline in last 3 Months No / Yes
1. Activities of Daily Living With Cognitive Decline _____(-2-21)
Without Cognitive Decline _____ (0-16)
TOTAL SCORE _____ (0-85)
75
4
5
6
0
0 0
0
8
2
25
Administer RAI in Clinic
Low RAI Score
Excellent Outcomes
Poor Outcomes
Surgical Techniques
Hospital Practices
High RAI Score
Further Workup
Comprehensive Geriatric
Assessment
Alternative Treatment
Appropriate Patient
Counseling
Thank you. Questions?
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