Frailty is associated with fewer hospital-free days following peripheral artery disease revascularization

OBJECTIVE: Many patients with peripheral artery disease (PAD) are frail and experience an increased risk of adverse outcomes, regardless of revascularization status. Hospital-free days (HFDs) represent an important patient-centered outcome as it accounts for both the early- and long-term utilization of hospital and emergency department care, as well as survival. We hypothesized that frail patients would experience fewer HFDs after lower-extremity revascularization for PAD. METHODS: We performed a retrospective analysis of adults undergoing an index lower-extremity revascularization for PAD (2016-2024) in a multihospital health care system. We defined frailty via the Risk Analysis Index adapted to the International Statistical Classification of Diseases, 10th Revision, Clinical Modification: not frail (<36) and frail (≥36). We defined our primary outcome, HFDs, as total days alive and outside of inpatient acute hospitals or emergency department visits, in a 90-day postoperative interval. Patients who died during the interval accrued zero additional HFDs after death. We modeled the association between frailty and PAD on HFDs using negative binomial regression, adjusting for age, demographics, and pertinent comorbidities not within the Risk Analysis Index. We generated adjusted rate ratios and 95% confidence intervals (CIs), as well as marginal adjusted mean HFDs. We compared secondary outcomes, including time-to-major amputation, major reintervention, and mortality using Kaplan-Meier curves and Cox models. RESULTS: In total, 11,436 adults (age, 71.1 ± 0.3 years; 62% male, 67% White) underwent revascularization for PAD, of which 17% were frail. Frail patients were more commonly older, men, and with comorbid diabetes, as well as pulmonary and coronary artery disease. Observed median HFDs was lowest among the frail patients (83 days [interquartile range, 73-88] vs 86 days [interquartile range, 80-89]) with PAD. On multivariable adjustment, the rate of HFDs was lower among frail patients (adjusted rate ratio, 0.95; 95% CI, 0.94-0.97; P = .01), which corresponded to 76 (95% CI, 75-77) vs 80 (95% CI, 79-80) adjusted HFDs in the 90 days after reintervention. Further, after multivariable Cox modeling, frailty was associated with a higher risk of major amputation [adjusted hazard ratio (aHR), 1.44; 95% CI, 1.12-1.84; P = .004] and mortality (aHR, 1.69; 95% CI, 1.49-1.92; P = .01), but a lower risk of major reintervention (aHR, 0.78; 95% CI, 0.64-0.94; P < .001). CONCLUSIONS: Among patients with PAD undergoing lower-extremity revascularization, frailty was associated with fewer HFDs. Frailty adversely affects limb and mortality outcomes, especially in the early postoperative period, reiterating the need for routine frailty screening, advanced perioperative care planning, and using data like these to inform shared decision-making between patient and clinicians.