The importance of frailty: Know thy patient

In this issue of the BJUI, Suskind et al. 1 used data from a large, national, prospectively designed surgical quality improvement initiative [the American College of Surgeons National Surgical Quality Improvement Program® (ACS-NSQIP)] to correlate patient frailty [measured using a previously validated 2 11-point NSQIP-Frailty Index (FI)] with 30-day postoperative outcomes for 21 common urological procedures. While two-thirds of the cohort was aged >60 years, interestingly, 80% had no more than one frailty item. Yet, the overall frequency of complications was 11.7%, which included 8.9% minor and 3.2% major complications (of which blood transfusion and readmissions were most common, respectively). Perhaps unsurprisingly, both frailty (odds ratio 1.74) and increasing age were independently associated with worse outcomes, even after controlling for other prognostic variables. Two important findings from the study deserve mention. While normal ageing-related changes may contribute substantially to greater frailty, as has been seen previously 3, 4, this study 1 shows that the effect of frailty was apparently not modified by patient age: for patients aged <80 years, increasing frailty independently predicts perioperative morbidity and mortality within each age group. Along with results by Revenig et al. 5, suggesting physician's subjective assessment of frailty may be over-reliant on patient age, this study 1 serves as a reminder for objective evaluation of frailty (even in younger patients) being considered for urological surgery. Along a similar note, while there was substantial heterogeneity in the association between increasing NSQIP-FI and complications across different urological surgeries, patients undergoing apparently minor procedures (such as TURP and hydrocoele) had unintended complications if they had a greater frailty index, the second important finding of this study. This may hold true for minimally invasive surgeries too: their widespread permeation and documented perioperative safety profile (when performed by experienced centres or high-volume surgeons) may make it easy to overlook the fact that frail patients are much more likely to experience complications than their healthier counterparts (5.9-times as likely, according to one study 3). Regardless, there are notable limitations and caveats in the results presented by Suskind et al. 1 that are as important to appreciate as its strengths. Although multiple frailty assessment tools exist 4, 6, including the NSQIP-FI used in this study, their clinical use may be limited by the time needed to complete them; as such, simplified tools (such as walking speed or hand-grip strength) that have recently been shown to be equally effective as full frailty assessment 5 may be more germane to a busy clinical setting. The ACS-NSQIP website also offers an online risk calculator (http://riskcalculator.facs.org/), which takes into account multiple variables, and can quantify the likelihood of postoperative mortality, overall- and organ-specific morbidity. Second, the authors grouped complications as ‘major’ or ‘minor’ in their current study 1: it may be more prudent to discuss complications according to the Clavien–Dindo system as has been done elsewhere in the context of urological oncology patients 6, which may be a more standardised approach to grading the severity of complications and their downstream management. Third, while it is plausible that frail patients are likely to have inferior perioperative outcomes, in general, there is a relative paucity of high-level evidence on specific interventions or techniques that can mitigate this risk, both in the elective and emergent surgery settings. Last but not least, a key consideration in optimising surgical outcomes is the degree of functional compromise and decline in health-related quality of life as a consequence of surgery, and formal association of preoperative frailty status with these postoperative metrics is warranted. As data on frailty and surgical complications continue to evolve, there is a need to incorporate objective, preoperative frailty assessment tools to allow better risk-stratification of patients into groups that are most likely to benefit from surgery and those where risks of surgery outweigh its benefits. Subsequently, high-quality perioperative care can improve outcomes (especially in older or frailer patients) and may reduce the burden of unintended complications and unplanned readmissions. To achieve both these aims efficiently, it is imperative upon us to become wiser and smarter in understanding what surgeries and patients risk facing complications postoperatively 7, and pursue further research on preoperative measures that can potentially mitigate this risk. Firas Abdollah is a consultant for GenomeDx Biosciences. Deepansh Dalela has nothing to disclose.