Frailty as a Predictor of Outcomes Following Major Lower Extremity Amputation Open Access

Abstract

Abstract

Frailty as a Predictor of Outcomes Following Major Lower Extremity Amputation

By: Zachary Fang

Objective:

Preoperative clinical frailty is increasingly used as a surrogate for a patient's ability to have a successful operative outcome. While previous reports have analyzed large national databases to correlate frailty with adverse results, there are limited single-center series demonstrating the same. Patients undergoing major lower extremity amputation (LEA) carry a high-risk of perioperative morbidity and mortality, including high 30-day readmission rates. We hypothesized that clinical evidence of preoperative frailty is associated with an increased risk of postoperative readmission.

Methods:

A retrospective review was performed for all patients who underwent above the knee (AKA) or below the knee (BKA) amputation for any indication within a single healthcare system over a five-year period. Data collected included standard demographics, insurance status, follow-up data, and components of the modified frailty index (mFI). Using the mFI, preoperative frailty status was determined for each patient. The primary outcome was 30-day mortality. Secondary outcomes included 30-day readmission and other postoperative complications.

Results:

Among 400 patients who identified, 379 were included in the analysis. The overall readmission and mortality rates as noted in patient charts for this group were 22.7% and 6.1%. Readmission rates increased with increasing mFI score: rates were 5.3%, 15%, 17.5%, 20.3%, 31%, and 35.5% for mFI scores of 0, 1, 2, 3, 4, and ≥5, respectively (p=0.015). On multivariate logistic regression comparing mFI score with age, race, operation type, insurance status, and surgical specialty, only mFI score was found to be a significant predictor of readmission (OR 1.417, CI 1.198-1.677, p<0.0001).

Conclusions:

Preoperative clinical frailty is associated with an increased 30-day readmission rate in patients undergoing LEA. As the mFI utilizes easily obtained historical information from the medical record, this analysis may be helpful in preoperative decision making for frail patients who are borderline candidates for operative therapy. Furthermore, preoperative frailty status should be considered when proposing standardized benchmarks for readmission.

Table of Contents

Table of Contents

I. Introduction…………………………………………………………………………… 1

II. Background…………………………………………………………………………... 2

III. Methods…………………………………………………..…………………………. 12

IV. Results………………………………………………………………………………. 16

V. Discussion………………………………..………………………………………...... 20

VI. References………………………………...…………...……………………………. 26

VII. Tables/Figures……………………………………………………………………... 30

List of Tables

Table 1: Components of the Modified Frailty Index…………………………………… 30

Table 2: Baseline demographics of patients undergoing major lower

extremity amputation from 2010-2015 stratified by Modified Frailty

Index (mFI) score (0 to ≥5)…………................................................................. 31

Table 3: Baseline demographics of patients undergoing major lower

extremity amputation from 2010-2015 stratified by Modified Frailty

Index (mFI) score ≤2 and >2…………………..………………….................... 32

Table 4: Baseline mFI components of patients undergoing major

lower extremity amputation from 2010-2015 stratified by mFI

score (0 to ≥5)………………………………..……………............................... 33

Table 5: Baseline mFI components of patients undergoing major

lower extremity amputation from 2010-2015 stratified by mFI

score ≤2 and >2…………………..……………………………………............. 34

Table 6: Outcomes after major lower extremity amputation stratified

by points scored (0 to ≥5) on Modified Frailty Index (mFI).............................. 35

Table 7: Outcomes after major lower extremity amputation stratified

by points scored on Modified Frailty Index (mFI) score ≤2 and >2…..………. 36

Table 8: Univariate and adjusted odds ratios for the effect of mFI

score (0 to ≥5) on outcomes ……………………..………………………......... 37

Table 9: Univariate and adjusted odds ratios for the effect of mFI

score (≤2 vs. >2) on outcomes ……………..…………………………………. 38

Table 10: Modified Frailty Index variables as predictors of 30-day mortality ………… 39

Table 11: Modified Frailty Index variables as predictors of 30-day readmission ……... 40

Table 12: Modified Frailty Index variables as predictors of unplanned revisions …….. 41

Table 13: Modified Frailty Index variables as predictors of adverse events ………… ...42

Table 14: Outcomes at Emory vs. Grady ……………………...……………………….. 43

List of Figures

Figure 1: Survival analysis of major lower extremity amputation

patients stratified by mFI score ………………………………………………. 44

Figure 2: Survival analysis of major lower extremity amputation

patients stratified by mFI score >2 (red) and ≤2 (blue)……………………..... 45

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research Curriculum Program
Degree	MS
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Aging Health Sciences, General
Keyword	Frailty Outcomes Amputations
Committee Chair / Thesis Advisor	Gillespie, Theresa Wicklin, Emory University
Committee Members	Barry, Vaughn, Emory University Klein, Mitchel, Emory University

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