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May 26, 2025British Journal of AnaesthesiaOpen Access

Directed acyclic graphs to minimise bias and optimise causal inference in SNAP-3: an observational cohort study of frailty, multimorbidity, and delirium in older surgical patients

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Key result

Directed acyclic graphs map relationships between frailty, multimorbidity, delirium, and postoperative outcomes in older patients.

Why the study?

The SNAP-3 study aims to describe the impact of frailty, multimorbidity, and delirium on postoperative outcomes in older surgical patients and to clarify causal assumptions using directed acyclic graphs.

Population

Older surgical patients in the SNAP-3 cohort

Comparison

Frailty, multimorbidity, and delirium as exposures

Design

Observational cohort study using directed acyclic graphs

Authors

CSClaire J SwarbrickRoyal Devon & Exeter NHS Foundation TrustHBHelen A. BlakeUniversity College HospitalPMPeter MartinRoyal College of Anaesthetists

Discussion

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Implication

DAGs may enhance causal modeling of frailty and delirium in surgical cohorts; leaves open the need for empirical validation before clinical application.

Study Design

Type

Cohort

Structured PICO

P
Population
Older surgical patients (SNAP-3 cohort)
E
Exposure
Frailty, multimorbidity, and delirium (as exposures)
O
Outcome
Postoperative outcomes (length of hospital stay, delirium, morbidity, mortality)

Directed acyclic graphs provide a transparent framework for statistical decision-making and causal inference in observational research.

Limitations

  • Complexities of exploring clinical relationships and the assumptions that are necessary

Cite This Study

Swarbrick et al. (2025) conducted a cohort in Frailty, multimorbidity, and delirium in older surgical patients. Frailty, multimorbidity, and delirium was evaluated on Postoperative outcomes (length of hospital stay, delirium, morbidity, mortality). Directed acyclic graphs were developed to model the exposure-outcome relationships between frailty, multimorbidity, and delirium with postoperative outcomes in older surgical patients.

synapsesocial.com/papers/6aaf306fec6de5f9fc39841ehttps://doi.org/10.1016/j.bja.2025.04.027
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Also Consider

Synapse has enriched 4 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Directed acyclic graphs in perioperative observational research–A systematic review and critique against best practice recommendations2023 · 10 citations
  2. 2Postoperative outcomes in older patients living with frailty and multimorbidity in the UK: SNAP-3, a snapshot observational study2025 · 44 citations
  3. 3Robust causal inference using directed acyclic graphs: the R package ‘dagitty’2016 · 2,363 citations
  4. 4Characteristics of older patients undergoing surgery in the UK: SNAP-3, a snapshot observational study2025 · 24 citations