Frailty and clinical results after elective and emergency general surgery in older adults: a national prospective multicenter observational study

Background: Frailty has emerged as a critical factor to predict postoperative outcomes in elderly surgical patients. This study aimed to evaluate the prevalence of frailty and its association with morbidity and mortality after elective and emergency general surgery in older adults across Spain, using two validated screening tools: the Clinical Frailty Scale (CFS) and PRISMA-7. Methods: We conducted a prospective, multicenter observational study including 32 Spanish hospitals. Patients aged >70 years undergoing general surgery between October and December 2022 were consecutively enrolled. Frailty was assessed preoperatively using CFS and PRISMA-7. The primary endpoint was 30-day mortality; secondary outcomes included overall postoperative complications, severity of complications, and hospital readmissions. Surgical complexity was categorized using the Operative Severity Score. Predictive performance was assessed using ROC curves. Results: A total of 2051 patients were included (median age 77). Frailty prevalence was 39.5% using CFS and 40.8% according to PRISMA-7. Overall, 30-day mortality was 6.2%, and 34% experienced at least one postoperative complication. Both scales showed good predictive value for mortality (AUROC 0.77 for CFS and 0.75 for PRISMA-7) but limited capacity for predicting complications or hospital readmissions (AUROC < 0.65). Frailty was independently associated with increased mortality, especially in procedures of higher complexity. Conclusions: Frailty is highly prevalent in elderly surgical patients and is a strong predictor of 30-day mortality. The systematic screening of frailty using validated tools such as the CFS and PRISMA-7 should be incorporated into perioperative care pathways to enhance risk stratification and support clinical decision-making.