The Frail Fail: Increased Mortality and Post-Operative Complications in Orthopaedic Trauma Patients Open Access

Abstract

Importance: The burgeoning elderly population calls for a robust tool to identify patients with increased risk of mortality and morbidity. The modified frailty index (MFI) is an important comprehensive assessment of postoperative complications in orthopaedic trauma patients.

Objective: To determine the effectiveness of the MFI as a predictor of morbidity and mortality in orthopaedic trauma patients.

Design: Retrospective review of database records

Setting: Participating hospitals in National Surgical Quality Improvement Project (NSQIP)

Participants: The NSQIP database was queried to identify patients age 60 and above who underwent surgery for pelvis and lower extremity fractures between 2005-2014.

Main Outcomes and Measures: For each patient, an MFI score was calculated using NSQIP variables. The relationship between the MFI score and 30-day mortality and morbidity was determined using chi-square analysis. MFI was compared to age, American Society of Anesthesiologists physical status classification, and wound classifications in multiple logistic regression.

Results: Study sample consisted of 36,424 patients with 27.8% male and 80.5% white with an average age of 79.5 years (SD 9.3). MFI ranged from 0 to 0.82 with a mean MFI of 0.12 (SD 0.09). As MFI score increased, mortality increased from 2.7% to 13.2% and readmission increased from 5.5% to 18.8%. The rate of any complication increased from 30.1% to 38.6%. Frail patients also had higher odds of adverse hospital discharge (MFI of 0.45+ OR: 8.6, 95% CI: 4.0-18.4). Length of hospital stay increased from 5.3 days (±5.5 days) to 9.1 days (±7.2 days) between MFI score 0 and 0.45+. There was a stronger association between MFI and 30-day mortality (adjusted OR for MFI 0.45+: 2.6, 95% CI: 1.7-3.9) compared to age (aOR for age: 1.1, 95% CI: 1.1-1.1) and ASA (aOR 2.5, 95% CI: 2.3-2.7).

Conclusions and Relevance: MFI was significantly associated with morbidity and mortality in orthopaedic trauma patients. Future direction will be to conduct a study to validate the index and compare to other morbidity scales. The use of MFI can provide an individualized risk assessment tool that can be used by an interdisciplinary team for perioperative counseling and to improve outcomes.

Table of Contents

TABLE OF CONTENTS

INTRODUCTION 1

METHODS 3

RESULTS 6

DISCUSSION 8

REFERENCES 13

TABLES 21

TABLE 1: Demographics 21

TABLE 2: Rate of outcome with increasing MFI score 22

TABLE 3: Thirty-day mortality association with MFI 23

TABLE 4: Thirty-day readmission association with MFI 24

TABLE 5: Clavien-Dindo complications association with MFI 25

FIGURES 26

FIGURE 1: Canadian Study on Health and Aging Frailty Index mapped to NSQIP modified frailty index 26

FIGURE 2: MFI distribution in patients with pelvis and lower extremity injuries 27

FIGURE 3: Length of stay by MFI score 28

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Surgery Health Sciences, Aging Health Sciences, Epidemiology
Keyword	Orthopaedics Modified Frailty Index Frailty Outcomes Geriatrics Trauma
Committee Chair / Thesis Advisor	Janssens, A Cecile, Emory University Schenker, Mara L, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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